Medical History Form Section 1: New Patient Intake FormBasic Patient InformationName First Last Email PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth Occupation Employer Gender Male Female Ethnicity Non-Hispanic Hispanic Education Level Emergency Contact Primary Doctor Referring Doctor Motor vehicle or workplace injury? Yes No What was the date of your injury? Briefly describe how your problem(s) began:Current MedicationsAllergiesDo you use tobacco products? Yes No Do you use marijuana? Yes No How often do you use marijuana? Does you consume alcohol? Yes No How many drinks per week? Previous SurgeriesExerciseSection 2: Location of Present Pain/DysfuntionPlease indicate where you suffer from pain or dysfunction and list from most to least severe. Be specific! ex. Inside of my right knee.Areas of Pain or DysfunctionSeverity of Pain Mild Moderate Severe From 0 (No pain) to 10 (Agonizing) - How is your pain when you're feeling best?012345678910From 0 (No pain) to 10 (Agonizing) - How is your pain at its worst?012345678910From 0 (No pain) to 10 (Agonizing) - How is your pain right now?012345678910Quality of Pain (You may select more than one) Aching Burning Sharp Cramping Spasming Numbing Electric Shock Frequency of pain Intermittent Continuous Waxes and Wanes Does your pain radiate? Yes No Where does your pain radiate? What makes your back or leg pain worse? (skip if you do not have back or leg pain) Lifting Twisting Weight bearing Prolonged sitting Prolonged standing Walking Uneven terrain Other What else makes your back or leg pain pain worse? What makes your neck, shoulder, or arm pain worse? (skip if you do not have neck, shoulder, or arm pain) Lifting Reaching overhead Reaching behind back Looking up or down Other What else makes your neck, shoulder, or arm pain worse? What makes your pain better? Nothing Rest Ice Heat Stretching Walking Sitting Standing Frequent positional changes Tylenol Ibuprofin Naproxen Muscle relaxant medication Other pain medications Exercise Physical therapy Chiropractic Massage Other What else makes your pain better? (You selected other) Treatments attempted: Nothing Ice or Heat Physical therapy Steroid injections NSAIDs (Ibuprofen, Aleve, Naproxin) Other treatments How often do you use NSAIDs? (You selected NSAIDs) Other treatments (You selected other) Does you have weakness? Yes No Where is your weakness? Do you have tingling, numbness,or decreased sensation? Yes No Where is your tingling, numbness, or decreased sensation? Do you limp when you walk? Yes No Section 3: Personal Medical HistoryPlease indicate if you suffer from any of the following conditions: Alcoholism Hepatitis AIDS Anemia Low platelet count Other bleeding disorder Sleep apnea Cancer Diabetes COPD Depression Anxiety Drug abuse Heart attack Heart disease Kidney disease Stroke Generalized joint hypermobility Migraines History of fainting Lyme disease Other chronic infection Gout Rheumatoid arthritis Psoriatic arthritis Reactive arthritis Other autoimmune condition Osteoporosis Scoliosis Ankylosing spondylitis DISH Low thyroid Low testosterone Low estrogen Other endocrine condition Ethlors-Danlos Syndrome What type of bleeding disorder? (You selected bleeding disorder above) What type of cancer? (You selected cancer above) What other type of chronic infection? (You selected other chronic infection above) What other autoimmune condition? (You selected other autoimmune condition above) What other endocrine condition? (You selected other endocrine condition above) Section 4: Review of SystemsPlease indicate if you are currently experiencing any of these symptomsConstitutional symptoms: Fever Weight loss Weight gain Extreme fatigue Eyes: Double vision Blurry vision Intolerance to bright light Ears: Hearing loss Tinnitus (ringing) Discharge Nose: Bleeding Discharge Congestion Post-nasal drip Mouth: Dental problems Bleeding gums TMJ Pain Cardiovascular: Chest pain Palpitations or irregular heartbeat Respiratory: Cough Wheezing Shortness of breath Trouble taking a deep breath Gastrointestinal: Nausea Vomiting Abdominal pain Constipation Diarrhea Blood in stools Loss of appetite Heartburn (GERD) Musculoskeletal: Other pains not already listed Other musculoskeletal pain - please explain:Skin: Rash Itching Abnormal Sweating Genitourinary: Irregular periods Vaginal bleeding after menopause Frequent or painful urination Bloody urine Impotence Pain with sex Neurological: Headache Sleep complaints Tingling or numbness Weakness Psychiatric: Depression Anxiety Suicidal thoughts Little interest or pleasure in doing things Endocrine: Excessive thirst Cold or heat intolerance Excessive urination or appetite Hair loss Very dry skin Leg/feet swelling Hematologic: Unusual bruising or bleeding Enlarged lymph nodes Edema Section 5: Family HistoryPlease indicate any individual in your immediate family who suffers from the following:Any history of family with similar problems to yours? Yes No Who in your family has similar problems to yours? Any history of family with disability? Yes No Who in your family has a disability? Any history of family with arthritis? Yes No Who in your family has arthritis? Any history of family with heart disease? Yes No Who in your family has heart disease? Any history of family with diabetes? Yes No Who in your family has diabetes? Any history of family with cancer? Yes No Who in your family has cancer? Any history of family with auto immune disease? Yes No Who in your family has auto immune disease? Any history of family with thyroid disease? Yes No Who in your family has thyroid disease? Any history of family with elevated cholesterol? Yes No Who in your family has elevated cholesterol? Any history of family with hypertension? Yes No Who in your family has hypertension? Other significant family history? Yes No Please explain any other significant family history Financial Policy Consent(Required) I agree to the financial policy.You, the patient, are responsible for your medical bills. If you are covered by an insurance which Vermont Regenerative Medicine bills, we will submit the forms for you and bill you for any remaining balance. If you have an insurance that we do not bill, we will give you a form which you can submit yourself. Not all insurances cover office visits and currently no regenerative medicine treatment is covered by any insurance. If you elect to proceed with a regenerative medicine procedure, you will be required to pay the full price on the day of the procedure. Co-pays and dispensary purchases are due at the time of service. I have read, understood, and agree to the Financial Policy. I authorize the release of any information necessary to process my claims. I also give permission for your office to leave a message on my phone. Privacy Policy Consent(Required) I agree to the HIPAA privacy policy.Vermont Regenerative Medicine HIPAA NOTICE OF PRIVACY PRACTICES Effective Date (January 1, 2024) This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this notice, please contact : Jonathan E. Fenton, D.O. at (802) 402-4979. This notice describes the privacy practices at our office. We are required by law to: Maintain the privacy of protected health information Give you this notice of our legal duties and privacy practices regarding your health information Follow the terms of the notice currently in effect. How we may use and disclose your health information Described as follows are the ways we may use and disclose your health information. Except for the following purposes we will use and disclose your health information only with your written permission. You may revoke such permission at any time by writing to Jonathan E. Fenton. Treatment – We may use and disclose your health information for your treatment and to provide you with treatment- related health care services. For example, we may disclose your health information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care. Payment – We may use and disclose your health information so that others or we may bill and receive payment from you, an insurance company, or a third party for the treatment and services you received. For example, we may give information to your health plan so that they will pay for your treatment. Health Care Operations – We may use and disclose your health information to evaluate and improve our medical care and to operate and manage our office. For example, we may use and disclose information to a peer review organization or a health plan that is evaluating our care. We may also share information with others that have a relationship with you for their health care operation activities. Appointment Reminders, Treatment Alternatives, and Health- Related Benefits and Services – We may use and disclose your health information to contact you and remind you of your appointment, to tell you about treatment alternatives or health-related benefits and services you could use. Individuals Involved in Your Care or Payment for Your Care – When appropriate, we may share your health information with a person involved in, or paying for, your care (such as your family or a close friend). We may notify your family about your location or condition or disclose such information to an entity assisting in disaster relief. Research – We may use and disclose your health information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another for the same condition. Before we do so, the project needs to go through a special approval process. Even without special approval, we may permit researchers to look at records to help identify patients who may be included in their research, as long as they do not remove or copy any of your health information. As Required by Law – We will disclose your health information when required to do so by international, federal, state or local law. To Avert a Serious Threat to Health or Safety – We may use and disclose your health information when necessary to prevent a serious threat to the health and safety of you, another person, or the public. Disclosures will be made only to someone who can prevent the threat. Business Associates – We may disclose your health information to our business associates that perform functions on our behalf or provide us with services if necessary. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose the information for any other purpose than appears in their contract with us. Military and Veterans – If you are a member of the armed forces, we may release your health information as required by military command authorities. If you are a member of a foreign military we may release your health information to the foreign military command authority. Worker’s Compensation – We may release your health information for worker’s compensation or similar programs that provide benefits for work-related injuries or illness. Public Health Risks – We may disclose your health information for public health activities to prevent or control disease, injury or disability. We may use your health information in reporting births or deaths, suspected child abuse or neglect, medication reactions or product malfunctions or injuries, and product recall notifications. We may use your health information to notify someone who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. If we are concerned that a patient may have been a victim of abuse, neglect, or domestic violence we may ask your permission to make a disclosure to an appropriate government authority. We will make that disclosure only when you agree or when required or authorized to do so by law. Health Oversight Activities – We may disclose your health information to a health oversight agency for activities authorized by law. These may include audits, investigations, inspections, and licensure. These activities are necessary to for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes – If you are involved in a lawsuit or dispute, we may disclose your health information in response to a court or administrative order. We may disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement – We may release your health information request by law enforcement official if 1) there is a court order, subpoena, warrant, summons or similar process; 2) if the request is limited to information needed to identify or locate a suspect, fugitive, material witness, or missing person; 3) the information is about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain your agreement; 4) the information is about a death that may be the result of criminal conduct; 5) the information is relevant to criminal conduct on our premises; and 6) it is needed in an emergency to report a crime, the location of a crime or victims, or the identity, description, or location of the person who may have committed the crime. Coroners, Medical Examiners, and Funeral Directors – We may release your health information to a coroner, medical examiner, or funeral director to identify a deceased person or cause of death, or other similar circumstance. National Security and Intelligence Activities – We may disclose your health information to authorized federal officials for intelligence and other national security activities authorized by law. Inmates or Individuals in Custody – If you are an inmate of a correctional institution or in custody we may disclose your information 1) for the institution to provide you with health care, 2) to protect your health and safety or that of others, and 3) for the safety and security of the institution. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION Right to Inspect and Copy – You have the right to inspect and copy your medical and billing records by written request to Jonathan E. Fenton. Right to Amend – You have the right to request an amendment to your records by written request to Jonathan E. Fenton. Right to an Accounting Of Disclosures – You have a right to an accounting of certain disclosures by written request to Jonathan E. Fenton. Right to Request Restrictions – You have the right to request restriction or limitation on your health information used for treatment, payment or health care operations. You may request us to limit disclosure to someone involved in your care or in payment for your care (such as a spouse) by written request to Jonathan E. Fenton. We are not required to agree with your request, but we will try to comply. Right to Request Confidential Communication – You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. You can ask, for example, that we contact you only by mail or at work. Your written request must specify how or where you wish to be contacted and be addressed to Jonathan E. Fenton. We will accommodate reasonable requests. CHANGES TO THIS NOTICE We may change this notice and make it effective for medical information we already have about you as well as new information. The current notice will be posted and available at all times. You have a right to request a paper copy of the current notice at any visit or by written request to Jonathan E. Fenton, D.O.CAPTCHA
