JOHN J. KATONA, M.D.BRIAN J. BAUER, M.D.JEFFREY K. STEUER, M.D.JAMES J. HALE, M.D.

Is this the result of an accident? YesNo

Welcome to our Practice Please make sure all information is complete and accurate

Patient Information

Sex: MF

MinorSingleMarriedPartnerDivorcedWidowedSeparated

primary insurance

additional insurance

***By initiating here you grant our office permission to receive your medication history electronically in order to prescribe your medication efficiently and correctly.

Reason for visit

medical history

1. Are you currently under medical Treatment?..... YesNo

2. Have you ever had any serious illness or operations?..... YesNo

3. Are you currently taking any medication?..... YesNo

4. Do you smoke?..... YesNo

5. Do you use alcohol?..... YesNo

6. Do you use cocaine or other drugs?..... YesNo

7. Have you had any allergic reactions to the following:

Local Anesthetics (eg. novocaine)......YesNo

Penicillin or other Antibiotics........YesNo

Sulfa Drugs............................YesNo

Barbituaries (sleeping pills)..........YesNo

Sedatives..............................YesNo

Iodine.................................YesNo

Aspirin................................YesNo

Other..................................YesNo

8. Women only:

Do you have regular periods?......YesNo

Are you taking birth control pills?......YesNo

Have you ever been pregnant?......YesNo

Have you ever had the following:

Anemia (low blood count)....YesNo Heart Murmur....YesNo Polio....YesNo

Anorexia (no appetite)......YesNo Heart Disease....YesNo Prostate Problem....YesNo

Arthritis.....YesNo Hepatitis Type.....YesNo Psychiatric Care....YesNo

Asthma........YesNo Hernia....YesNo Respiratory Disease....YesNo

Back Problems....YesNo Herpes....YesNo Rheumatic Fever....YesNo

Bleeding Tendency....YesNo High Blood Pressure....YesNo Scarlet Fever....YesNo

Blood Disease....YesNo HIV/AIDS....YesNo Shortness of Breath....YesNo

Cancer....YesNo Jaundice....YesNo Sinus Trouble....YesNo

Chemical Dependancy (addiction to drugs)YesNo Kidney Disease....YesNo Skin Rash....YesNo

Chemo Therapy....YesNo Latex Sensitivity....YesNo Stroke....YesNo

Chicken Pox....YesNo Liver Disease....YesNo Thyroid Problems....YesNo

Chronic Fatigue Syndrome....YesNo Low Blood Pressure....YesNo Tonsillitis....YesNo

Circulatory Problems....YesNo Measles....YesNo Tuberculosis....YesNo

Congenital Heart Lesions....YesNo Migrane Headaches....YesNo Ulcer....YesNo

Cough - Persistent or bloody....YesNo Mitral valve Prolapse....YesNo Venereal Disease....YesNo

Diabetes....YesNo Mumps....YesNo Any other Condition....YesNo

Emphysema....YesNo Multiple Sceriosis....YesNo

Epllepsy....YesNo Pacemaker....YesNo

Glaucoma....YesNo Pneumonia....YesNo

assignment & release

I hereby authorize payment directly to for all insurance benefits otherwise payable to me for services rendered. I understand that i am financially responsible for all charges, whether or not paid paid by insurance, and for all services rendered on my behalf or my dependents. I am financially responsible for any collection or attorney fees resulting from default of my account.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Acknowledgement of Receipt of Notice of Privacy Practices

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information ("PHI") about you. You have the right to review our notice and ask questions about our privacy practices. as provided in our Notice, the terms of our Notice may change. If we change our Notice, you will receive a revised copy at the time for first service after the change.

You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment or healthcare operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

By signing this form you acknowledge that you have received our 'Notice of Privacy Practices'.

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