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Premier Rheumatology and Endocrinology Renanit E. Barron, M.D.

5155 Corporate Way • Suite C • Jupiter, FL 33458 5730 Corporate Way • Suite 200 • West Palm Beach, FL 33407

Tel: 561-881-3022 Fax: 561-881-3088

PATIENT INFORMATION

Please print and complete as accurately as possible Name: ________________________________________________________________________ Last First Middle Mailing Address: ______________________________________________________ City: _________________________ State: ________ Zip:_________ Home Phone: ( ) __________ Cell Phone: ( ) __________ Other Address (if applicable): _____________________________________________ City: _________________________ State:________ Zip:_________ Phone ( ) __________ Social Security Number: _______-_______-_______ Date of Birth: _____/_____/______ Age: ______ Month Day Year How did you hear about us? _________________________________________________________ YOUR EMPLOYER INFORMATION (if applicable) Name of Employer: _________________________________ Phone: ( ) _______________ Address: __________________________ City___________________ State______ Zip Code_______ SPOUSE EMPLOYER INFORMATION (if applicable) Name of Employer: _________________________________ Phone: ( ) _______________ Address: __________________________ City___________________ State______ Zip Code_______ INSURANCE INFORMATION Insurance Company: ________________________________________________________________ Address: ___________________________________________________________________________ City: ________________________ State: ________ Zip: ___________ Phone: ( ) _______________ Policyholder Name: ____________________________________________________________________ Your relation to policy holder: □ Self □ Spouse □ Dependent Child Social Security Number of Policyholder___________________ Date of Birth of Policyholder_______________________

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Premier Rheumatology and Endocrinology Renanit E. Barron, M.D.

5155 Corporate Way • Suite C • Jupiter, FL 33458 5730 Corporate Way • Suite 200 • West Palm Beach, FL 33407

Tel: 561-881-3022 Fax: 561-881-3088

OFFICE POLICIES AND PROCEDURES

Welcome to our practice. The following information contains office policies and procedures that we feel are necessary for you to read and fully understand. MAKING APPOINTMENTS: Our staff will schedule appointments during normal business hours. WE DO NOT ACCEPT “WALK-INS” at this office. All visits are “BY APPOINTMENT ONLY”. MISSED APPOINTMENTS: If you are unable to keep an appointment, we ask that you kindly provide us with at least 24 business hours' notice. This courtesy on your part will make it possible to give your appointment to another patient. If you do not call to cancel/re-schedule or do not show up for your appointment, you will be billed a $25.00 “no show” fee. If you miss two scheduled appointments, without the courtesy of canceling them, you may be dismissed from our practice. EMERGENCIES: If you have an emergency you should call 911 or proceed to the emergency room. RETURN PHONE CALLS: Any requests for a return phone call from Dr. Renanit Barron MUST BE EXPLAINED to the office staff prior to receiving a return call. Any “private matters” that you do not want to discuss with our staff, will require a scheduled appointment. If your message is NOT of an urgent nature, leave a message and it will be handled accordingly. MEDICATION REFILLS: It is your responsibility to make sure that you do not run out of your medication. If you are taking long-term medications, refills will be handled at the time of your office visit. Please check your bottles prior to your appointment. If you need a refill, you must have your pharmacy fax a request and it will be considered within 72 business hours. If you have missed your appointment it will be filled at the discretion of the physician. Many medications require close monitoring of labs; therefore, you need to be seen in order to get a refill. This is for your own safety. REFERRALS: If your insurance company requires you to have a referral for your visit, it is your responsibility to obtain it from your primary care physician. If you do not have a referral at the time of your visit you may not be covered and you will be responsible for the charges. SIGNATURE: Please read and sign to acknowledge receiving these policies. Thank you again for choosing our practice. Name:_________________________________________ Date:____________________

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Premier Rheumatology and Endocrinology Renanit E. Barron, M.D.

5155 Corporate Way • Suite C • Jupiter, FL 33458 5730 Corporate Way • Suite 200 • West Palm Beach, FL 33407

Tel: 561-881-3022 Fax: 561-881-3088

Release of Information

I authorize the release of any of my medical information necessary to process any of my insurance claims. I permit a copy of this authorization to be used in place of the originals. Signature: _________________________________________

Assignments of Benefits

I authorize payment of medical benefits to Premier Rheumatology and Endocrinology (Rheumatology and Endocrinology Specialists of the Palm Beaches) for services rendered. I understand that I am responsible for all charges not covered by medical insurance. In addition, I am responsible for any deductible, co-pay and co-insurance amounts. Signature: _________________________________________

Consent for Treatment

I authorize and consent for the performance of office procedures deemed necessary by the physicians and their staff. Signature: _________________________________________

Notice of Privacy and Practices Written Acknowledgement

I have received a copy or have read on Dr. Barron’s website, the notice of privacy practices for Premier Rheumatology and Endocrinology. Signature: _________________________________________ Date: ________________

Phone Numbers for Messages I authorize Dr. Adam Barron and/or Dr. Renanit Barron, and their staff to leave phone messages for me at the following numbers. I understand that these messages may contain my private health information List Phone #’s: 1. ( ) _____________ 2. ( ) _____________ 3. ( ) _____________ --------------------------------------------------------------------------------------------------------------------------------- I understand that Dr. Adam Barron’s practice focuses on Rheumatology and Dr. Renanit Barron’s practice focuses on Endocrinology. Both physicians do not serve as primary physicians. If I do not have a primary care physician, it is recommended that I establish care with one. Additionally, Drs. Barron do not serve as admitting physicians to hospitals. If I have an urgent medical problem related to Rheumatology I may contact Dr. Adam Barron, or if I have an urgent problem related to Endocrinology I may contact Dr. Renanit Barron. If I am unable to reach them then I will contact my primary care physician or seek care in an emergency room. All other problems and issues should be directed toward my primary care physician, other specialists who I am seeing, or an emergency room. Non-urgent issues should be directed to the office during regular office hours. Signature: _____________________________________

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ENDOCRINOLOGY NEW PATIENT QUESTIONNAIRE Renanit E. Barron, M.D.

1. The name and address of the physician providing your primary care?

_______________________________________________________

2. You were referred here by? ___Self___Family___Friend___Doctor___Other

3. Reason for your visit to Endocrinology Office____________________

4. When did you first notice this problem?______/_____(month/year)

5. Have you had Ultrasounds, CT Scan or MRI for this problem ___yes___no

6. Please name other practitioners you have seen for this problem? _________________________________________________________

7. Previous treatment for this problem?_____________________________

MEDICATION

Name of Medication Dose # at a time

#times per day

Name of Medication Dose # at a time

# times per day

1 7

2 8

3 9

4 10

5 11

6 12

List any medicines you are allergic to and the reaction:

_____________________________________________________________________________

List any vitamins, supplements or herbs:

_____________________________________________________________________________

Social History:

1. Occupation______________________________________________________________ 2. Level of Education________________________________________________________ 3. Your Marital Status_______________________________________________________ 4. Have you ever smoked cigarettes?____________________________________________

a. If yes, how may packs per day and for how many years_____________________ 5. Do you drink alcohol?______________________________________________________

a. If yes, please list type and number of glasses per day:______________________ 6. Have you ever used illegal or recreational drugs?________________________________

a. If yes, please list type:_______________________________________________

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Patient Name: ________________________________

Family History: Do you know of any blood relatives who have or had the following conditions? ____ Diabetes ____ High blood pressure ____ Pituitary disease ____ Thyroid disease ____ Cancer ____ Stroke ____ Heart disease ____ Other significant illnesses, list: _________________ Review of Systems Review of Systems Constitutional Systems Recent weight gain…………………__No __Yes Amount……………………………. __________ Recent weight loss……………….. __No __Yes Amount …………………………… __________ Fever ……………………………... __No __Yes Fatigue…………………………...... __No __Yes Headaches……………………….….__No __Yes Eyes Pain………………………………… __No __Yes Dryness ……………………………. __No __Yes Wear glasses or contact lens ………. __No __Yes Blurred or double vision …………... __No __Yes Ears/Nose/Mouth/Throat Hearing loss or ringing …………... __No __Yes Earaches or drainage …………….... __No __Yes Chronic sinus problem or rhinitis...... __No __Yes Nose bleeds ………………………... __No __Yes Mouth sores ……………………….. __No __Yes Bleeding gums …………………..… __No __Yes Sore throat voice change …………... __No __Yes Swollen glands in neck ……………. __No __Yes Difficulty swallowing ……………... __No __Yes Cardiovascular Chest pain ………………………...... __No __Yes Palpitation …………………………. __No __Yes Shortness of breath/walking /laying...__No __Yes Asthma or wheezing ………………. __No __Yes Gastrointestinal Loss of appetite ……………………..__No __Yes Change in bowl movement ………... __No __Yes Nausea or vomiting ……………….. __No __Yes Frequent diarrhea …………………. __No __Yes Painful bowl/constipation …………. __No __Yes Rectal bleeding/blood in stool ……. __No __Yes Abdominal pain or heartburn……….__No __Yes Peptic ulcer (stomach/duodenal) … __No __Yes

Genitourinary Frequent urination………………… __No __Yes Urinating at night…………………... __No __Yes Burning or painful urination ………. __No __Yes Blood in urine ……………………... __No __Yes Incontinence or dribbling ……….. .. __No __Yes Kidney stone ……………………… __No __Yes Sexual difficulties ………………… __No __Yes Musculoskeletal Joint Pain ……………………………__No __Yes Joint stiffness or swelling …………...__No __Yes Weakness of muscle or joint ………. __No __Yes Muscle pain or cramps ……………...__No __Yes Back pain …………………………...__No __Yes Integumentary (skin, breast) Rash or itching ………………………__No __Yes Change in skin color ……………… __No __Yes Change in hair or nails ………………__No __Yes Breast discharge ……………………..__No __Yes Neurological Frequent or recurring headaches …… __No __Yes Light headed or dizzy ………………..__No __Yes Numbness or tingling sensations …….__No __Yes Tremors ……………………………...__No __Yes Paralysis ……………………………..__No __Yes Stroke ………………………………..__No __Yes Head injury …………………………..__No __Yes Psychiatric Memory loss or confusion …………...__No __Yes Nervousness …………………………__No __Yes Depression …………………………...__No __Yes Insomnia ……………………………..__No __Yes Endocrine Excessive thirst or urination …………__No __Yes Heat or cold intolerance ……………..__No __Yes Skin becoming dryer ………………...__No __Yes Change in shoe or ring size ………….__No __Yes

Women Only Age when period began? _______________ Period regular? ____ Yes ____ No How many days apart? _________________ Date of last period? ___________________ Date of last pap? ______________________

Women Only Bleeding after menopause? ____ Yes ____No Age at menopause? ___________________ Pregnancy (ies) _____ Yes _____ No Number ______________________ Miscarriage? _____ Yes _____ No Number ___________

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Patient Name: ________________________________

PAST MEDICAL HISTORY: Please check if you have had any of the following conditions:

HEAD/EARS/EYES/THROAT

Cataract

Glaucoma

Migraine Headaches

Sinus Infections

HEART

Rheumatic Fever

Heart Attack/Myocardial

Infarction

Heart Murmur

Angina

Heart Failure

Heart Palpitation

High Blood Pressure

ENDOCRINE

Thyroid Disease

Diabetes

Goiter

SKIN

Skin Ulcers – Lower Leg

Fingers Turning

White/Raynaud’s

Psoriasis

Other Rashes

Other Skin Conditions:

_____________________

GENITOURINARY

Nephritis/Kidney Disease

Kidney Infection

Kidney Stones

Syphilis

Gonorrhea

Chlamydia

Genital Herpes

LUNGS

Tuberculosis/TB Exposure/

Positive TB Skin Test

Emphysema

Pneumonia

Pleurisy

Blood Clot in Lung

Asthma

GASTROINTESTINAL

Stomach/Duodenal Ulcer

Cirrhosis

Hepatitis

Gallstones

Pancreatic Disease

Intestinal Polyp

MUSCULOSKELETAL

Rheumatoid Arthritis

Gout

Lupus

Serious Joint Injury (ies)

Broken Bones

Disabling Back Pain

Degenerative Arthritis

Osteoporosis

HEMATOLOGY/ONCOLOGY

Anemia

Blood transfusions

Blood Clots in Leg

Bleeding Tendency

Cancer

Type: _________________

Tattoos

GASTROINTESTINAL cont.

Esophageal Disease/Reflux

Colitis

Diverticulitis

Crohn’s disease

Irritable Bowel Syndrome

NEUROLOGIC/PSYCHIATRIC

Meningitis

Stroke/Paralysis

Seizures/Epilepsy

Depression

Nervous Breakdown

OTHER

Alcoholism

Drug Abuse

HIV Testing Yes No

Result: ____________ Other (explain)_________

________________________

Cancer Type: _________________ AIDS

WOMEN ONLY

Pregnancy(ies) & Number

Miscarriage(s) & Number

Toxemia/Eclampsia

Patient Name: ________________________________ OTHER SIGNIFICANT ILLNESS(ES) List:__________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Please list all of your previous hospitalizations and surgeries below:

CONDITION OR PROCEDURE YEAR CONDITION OR PROCEDURE YEAR

1 6

2 7

3 8

4 9

5 10

Please list all physicians you are currently seeing: 1. PHYSICIAN'S NAME SPECIALTY PHONE NUMBER

ADDRESS

2. PHYSICIAN'S NAME SPECIALTY PHONE NUMBER

ADDRESS

3. PHYSICIAN'S NAME ADDRESS 4. PHYSICIAN'S NAME ADDRESS 5. PHYSICIAN'SNAME ADDRESS 6. PHYSICIAN'S NAME ADDRESS PATIENT’S SIGNATURE_____

___

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SPECIALTY PHONE NUMBER

SPECIALTY PHONE NUMBER

SPECIALTY PHONE NUMBER

SPECIALTY PHONE NUMBER

____________________________________________________