A note from Dr. Lee
Credentials
Please fill out the information below and click submit.
PERSONAL INFORMATION:
NAME: *
EMAIL: *
Male Female  
STREET: *
CITY: *
STATE: *
ZIP: *
HOME PHONE:
CELL PHONE: *
BIRTH DATE: *
PLACE OF BIRTH: *
AGE:
SS#: *
DRIVER'S LIC. #: *
EMPLOYED BY:
ADDRESS:
CITY:
STATE:
ZIP:
OCCUPATION:

   
INSURANCE INFORMATION:
PRIMARY INSURANCE:
INSURANCE NAME: *
INSURANCE TYPE:  
STREET:
CITY:
STATE:
ZIP:
PHONE:
POLICY #: *
GROUP #: *
CERTIFICATE #
SUBSCRIBER #:
   
SECONDARY INSURANCE:
INSURANCE NAME:
STREET:
CITY:
STATE:
ZIP:
PHONE:
POLICY #:
GROUP #:
CERTIFICATE #:
SUBSCRIBER #:
   
NEAREST RELATIVE NOT LIVING WITH YOU:
NAME: *
RELATIONSHIP: *
PHONE: *
   
SIGNIFICANT OTHER:  
NAME: *
PHONE: *
   
WHO SHOULD WE CONTACT IN CASE OF AN EMERGENCY?
NAME: *
PHONE: *
   
*NOTE, YOUR INSURANCE IS A CONTRACT BETWEEN YOU, YOUR EMPLOYER, AND THE INSURANCE COMPANY. WE ARE NOT A PARTY TO THAT CONTRACT.

I UNDERSTAND AND AGREE THAT, REGARDLESS OF MY INSURANCE STATUS, I AM ULTIMATELY RESPONSIBLE FOR THE BALANCE ON MY ACCOUNT FOR ANY PROFESSIONAL SERVICES RENDERED. THERE WILL BE A 1.5% INTEREST CHARGE PER MONTH AND A 30% COLLECTION FEE FOR OVERDUE ACCOUNTS. I HAVE READ ALL THE INFORMATION AND HAVE COMPLETED THE ABOVE ANSWERS. I CERTIFY THIS INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

I AGREE TO THE ABOVE*

YES NO  
   
ASSIGNMENT OF INSURANCE BENEFITS
IF THERE IS INSURANCE COVERAGE FOR THIS PERIOD OF HOSPITALIZATION AND/OR PROFESSIONAL
SERVICES, PLEASE FILL OUT THIS AUTHORIZATION AND IT WILL BE FORWARDED TO YOUR INSURANCE
COMPANY FOR PAYMENT.
TO (INSURANCE COMPANY): *
STREET: *
CITY: *
STATE: *
ZIP: *
   
I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE BELOW NAMED PHYSICIAN AS INDICATED HEREIN OF ALL HOSPITAL OR PROFESSIONAL EXPENSE BENEFITS PAYABLE TO ME, BUT NOT TO EXCEED THE REGULAR CHARGES OF FEES FOR THIS PERIOD OF HOSPITALIZATION OR PROFESSIONAL SERVICES. I DO UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ANY AMOUNTS THAT ARE NOT PAID THROUGH MY INSURANCE COMPANY. INSURANCE IS BILLED ONLY AS A COURTESY. I UNDERSTAND THAT PROFESSIONAL SERVICES AND CHARGES ARE ULTIMATELY MY RESPONSIBILITY.

I AGREE TO THE ABOVE*
YES NO  

   

Patient Health History Questionnaire
All information is confidential. Please answer all questions carefully and completely.
 
Why did you come to see the doctor today?
   
Childhood illnesses: (Please X all that apply)
Measles Mumps Rheumatic fever Tuberculosis
Chicken pox Scarlet fever Asthma Pneumonia
Seizures Other:
 
Adult illnesses: (Please X all that apply)
Heart disease Stroke Diabetes Pneumonia
High blood pressure Emphysema Tuberculosis (Tb) Seizures
Positive Tb test Cancer Blood transfusions  
Hepatitis (what type?)
Others:
 
 When did you first test positive for HIV?
Risk factors for HIV infection:
 
HIV-related conditions: please X all that apply
Oral thrush(yeast) Pneumocystis pneumonia Cytomegalovirus(CMV)
Kaposi's Sarcoma Mycobacterium (MAC) Oral hairy leukoplakia
Shingles Toxoplasmosis Anemia
Molluscum    
Other:

Surgeries: (Please X all that apply)

Tonsils Appendix Gallbladder Joints or bones
Wisdom teeth Eyes Spleen  
Other surgeries:
 
Medical/Surgical Hospitalizations:
Year Reason: # of days:
     
Psychiatric Hospitalizations:
Year Reason: # of days:
 
Current Medications:
Name: Dose: When started:
Others:
 
OTC medications (ex. Tylenol, cold pills, nose sprays):
 
Vitamins
 
Holistic, alternative or herbal preparations
 
Allergies to medications, foods, plants, animals or other products
(list name of product and type of reaction):
yes no    
Specify:
 
Past Medications:
(please X if you have ever taken these)
NRTI    
Epivir- 3TC, Lamivudine Emtriva-FTC, Emtricitabine Hivid- DDI, Zalcitabide
Retrovir- AZT, Zidovudine Videx- DDI, Didanosine Viread- TDF, Tenofovir
Ziagen- Abacavir, ABC Zerit- D4T, Stavudine  
COMBO NRTI    
Combivir- Retrovir, AZT, Zidovudine + Epivir-3TC, Lamivudine
Epzicom- Ziagen, Abacavir, ABC + Epivir- 3TC, Lamivudine
Trizivir- Retrovir, AZT, Zidovudine + Epivir- 3TC, Lamivudine + Ziagen- Abacavir, ABC
Truvada- Emtriva, FTC, Emtricitabine + Viread- TDF, Tenofovir
NNRTI
Sustiva- Efavirenz, EFV Rescriptor- Delavirdine, DLV Nevirapine, NVP
NRTI + NNRTI COMBO  
ATRIPLA, Sustiva- Efavirenz, EFV + Emtriva- FTC, Emtricitabine + Viread- TDF, Tenofovir
PI  
Angenerase- Amprenavir, APV Aptivus- Tipranavir, TPV Crixivan- Indinavir, IDV
Fortovase- Invirase, Saquinavir, SQV Invirase- Saquinavir, SQV Lexiva- Fosamprenavir, FAPV
Lopinavir- See Kaletra Norvir- Ritonavir, RTV Prezista- Darunavir
Reyataz- Atazanavir, ATV Saquinavir- Invirase, SQV Viracept- Nelfinavir, NFV
PI COMBO    
Kaletra- Lopinavir, LPV + Norvir- Ritonavir, RTV
FUSION INHIBITOR
Fuzeon- T-20. Enfurvitide, ENF
OTHER
Hydroxyurea- Hydrea
HIV RELATED :  
Bactrim Biaxin Cytovene
Diflucan Dapsone Mycobutin (rifabutin)
Sporonox Zovirax  
OTHERS NOT LISTED:  
 
Immunizations:
Last tetanus:
Last TB test:

 

Family History:
Are you adopted? Yes No
   
Father:  
If living, age:
Health problems:
If deceased, age at death:
Cause of death:
   
Mother:  
If living, age:
Health problems:
If deceased, age at death:
Cause of death:
   
Brothers:  
Total #
Ages:
Health problems:
   
Sisters:  
Total #
Ages:
Health problems:
   
Please note if you have any relatives with the following conditions (and who it is):
Cancer:
Alcohol or drug abuse:
Diabetes:
Heart disease:
High blood pressure:
 
Social History (please X all that apply):
Sexual orientation:
straight (heterosexual) gay lesbian
bisexual transgendered transsexual
 
Marital History:
single lover or married (opposite sex) lover or married (same sex)
never married living together separated
widowed divorced  
 
Children:
# of boys: ages:
# of girls: ages:
 
Employment:
Are you currently employed? yes no
describe job:
If unemployed, are you disabled? yes no
reason:
 
Habits--do you use any of the following:
  Never Occasional 1-2 times/ week 3-4 times/week Daily
Alcohol:
Marijuhana
Cocaine/crack:
Speed/crystal:
Heroin/opiates:
Other Drugs:
           
Have you ever injected drugs into a vein? yes no

Have you every had any legal problems due to alcohol or drugs:
yes no
describe:
 
Cigarettes:    
Never Smoked    
Quit when:
Smoked packs per day for years.
Currently smoke packs per day.  
 
Review Of Systems
Please describe any symptoms or concerns you have in the following body areas:
Skin:
Head:
Eyes:
Ears:
Nose:
Throat:
Neck:
Heart:
Lungs:
Blood and Blood Vessels (veins, arteries):
Gastrointestinal (stomach, bowels, rectum, etc):
Genitourinary (kidneys, bladder, genitals):
Muscles and Joints:
Brain and Nerves:
Psychological and Emotional:
 
STD Related Conditions (Please X all that apply)
Herpes Genital warts Chlamydia
Gonorrhea Syphillis Trichomonas
Other:
 
Contacts
How may we contact you with insurance questions, confidential lab results or general questions. (Please X all that apply)
    routine urgent
Email *
Home #
Work #
Cell # *
Pager#
Fax #
 
I do authorize to receive correspondence at the above numbers and/or addresses*
Yes No    
 
Is there anything else you would like us to know about you?
 
Please indicate the address you want us to use to send information and/or billing:
STREET: *
CITY: *
STATE: *
ZIP: *
   
DATE: *