New Patient Packet – El Centro – Cabrillo Center For Rheumatic Disease


Date:
Welcome New Patient
You have been referred by Dr/NP/PA:
for
Your rheumatology consultation visit with Dr/NP:
has been scheduled on
Email:


Welcome to the Cabrillo Center for Rheumatic Disease specialty clinic. Please initial belowthat you have read and understand our check in policy. Thank you for your time and effort in your healthcare, as we cannot do our best without your help.
Check In Policy for New Patients
YOU MUST ARRIVE 30 MINUTES PRIOR TO YOUR APPOINTMENT WITH YOUR NEW PATIENT PACKET COMPLETED. YOU WILL BE RESCHEDULED IF YOU DO NOT ARRIVE 30 MINUTES PRIOR TO YOUR NEW PATIENT APPOINTMENT AND/OR YOUR NEW PATIENT PACKET IS NOT COMPLETED.

Check In Policy for Follow-up Appointments
ARRIVE 15 MINUTES PRIOR TO YOUR SCHEDULED FOLLOW UP APPOINTMENT TO ALLOW TIME TO UPDATE YOUR INSURANCE AND ADDRESS, PAY YOUR COPAY, AND COMPLETE VITALS. YOU WILL BE RESCHEDULED IF YOU DO NOT CHECK IN 15 MINUTES PRIOR TO YOUR FOLLOW UP APPOINTMENT.

Please note the following:
➢ We refer patients who need pain medication to pain specialty clinics.
➢ We refer patients back to their primary care physician for non-rheumatic issues. If you do not have a primary care physician we will refer you to one.
➢ Please bring an interpreter if you are concerned that you will be unable to provide an accurate history in English. Please bring copies of results of abnormal labs or x-rays (images if possible) that caused you to be referred to us.

Cabrillo Center for Rheumatic Disease 1420 Ocotillo Dr, Ste B El Centro, CA 92243 Phone: 760-309-1288 \| Fax: 760-970-4270

Cost of Filling Out Forms and Generating Letters

Cabrillo Center for Rheumatic Disease charges for forms to be filled out by our office that are not pertinent to direct daily
patient care paperwork (i.e. lab orders, x-ray orders, prescriptions, and medical records) as these forms create extra work
that is not covered by your insurance. These forms are not considered a standard part of patient medical care. Below is an updated
list of various forms not covered by insurance and their costs.

$0	Excuse note for work, school, or jury duty (Completed on a prescription pad paper note- no letterhead)
$20	Form requiring Signature only
$25	Department of Motor Vehicle parking placard form, Family Medical Leave Act form
$30/page	Letters requiring letterhead that are not disability related
$50/page	Disability forms and disability letters (separate appt may need to be made)
$0.50/page	Chart copies (if more than just a single lab or x-ray report or office note), but we can fax copies to any doctor at no cost.

Policy Statement

Privacy Practices: I understand that this medical office reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by requesting it in writing (either by mail or at my next appointment) and a revised copy may be sent in the mail or will be provided to me at the time of my next appointment.

Please indicate whether you should like a copy of the Notice of Privacy Practices: YESNO

Confidentiality: Professional ethics and California state law specifies that communications to medical staff are confidential and privileged and cannot be released or shared without the express written permission of the patient, except as noted above. However, there exist a few instances that are mandated by law to report certain information. These include, but are not limited to abuse of a minor, or if you express the intent of bringing harm to yourself or another person. In such circumstances, the provider is required to inform potential victim(s) and legal authorities.

Cancellation: Your appointment time has been reserved exclusively for you. I agree that if I fail to cancel my appointment within at least 24-hours notice, I will be billed a $25 cancellation fee. I understand that this fee is the patient’s responsibility, as missed appointments are not covered by insurance.

No-Show Policy: Patients are subject to a $50 charge for missing their scheduled appointment. This fee is the patient’s responsibility, as it is not covered by insurance.

If you do not show for your appointment three (3) times you may be discharged from the clinic

Late Fee Policy: Patients that arrive 15 minutes after their scheduled appointment time are not guaranteed to be seen the same day. Patients may reschedule for another day.

Coordination of Care:

Insurance: This office will submit your insurance claims to you carrier at no cost to you. However, we are not in a position to guarantee payment from your insurance company because the claim is based upon arrangements between you and the insurer. Please be aware that it is common for insurance companies to subcontract certain benefits to another company. In these instances, we may not bill your insurance company; we may be required to bill your medical group or a third-party payer. I understand that it is my responsibility to know if this is true.
Prior Authorization: Prior authorization may be required before your first visit. Please be aware that it is your responsibility to know if this is true for your insurance coverage(s), and to get the necessary authorization(s).
Medical Records: I understand that CCRD will retain my medical records for seven years as per legal requirements. Copies of records can be transferred to other health care providers upon receipt of a valid written consent. I understand that this office requires at least 72 hours notice prior to medical records being made available to the authorized party.
Medications: I understand that medical refills will be considered during office hours only. This is so the office can conform with California Pharmacy statutes, and to prevent the possibility of other persons from acting or posing as patients of CCRD or obtaining medication illegally. I further understand that if I need to have a prescription refilled that I should contact my pharmacy 1-2 days prior to needing the medication or the medication may not be available to me the same day. I understand refills for any medication will not be performed unless I have been seen within the last 6 months.
Agreements: I have reviewed the preceding information, and I certify that this information is accurate. I further understand that I am responsible for any financial loss due to incomplete or inaccurate information provided by myself.
I hereby authorize payment directly to this medical provider any insurance benefits that would otherwise be payable to me for services rendered.
In instances where insurance does not pay any benefits, I agree to pay for those services. If payment is not received within 90 days from the date the claim was submitted, I agree that I will become responsible for the full amount for the balance on my account.
Should I break the financial arrangements as detailed above, I agree that my name may be released for collection purposes. I understand that no treatment related information will accompany this disclosure. I also agree that if any legal action is taken to enforce the provisions of this Policy Statement that the prevailing party shall be entitled to reasonable attorney’s fees and costs.
Please sign below to indicate that you have read the Policy Statement and agree to the terms as stated
Signature:		Date:
Rheumatic diseases can affect many different body systems, which therefore can require communication between doctors of different specialties. In order to provide you with the most well-rounded care possible, your provider may request to see ecords/results of your visits with other providers. The following page is a form that will allow your other healthcare providers to share your health information with your provider at CCRD. This release is 100% voluntary and can be revoked at any time.

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

Name:	Date of Birth:
Recipient: I authorize my health care information to be released to the following recipient(s).
Cabrillo Center for Rheumatic Disease 1420 Ocotillo Dr, Ste B El Centro, CA 92243 Phone: 760-309-1288 \| Fax: 760-970-4270
Purpose: I authorize the release of my health information for the following specific purpose.
Coordination of Care
Information to be disclosed: I authorize the release of the following health information: (check the applicable box below)
All of my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me.Only the following records or types of health information.

Term: I understand that this Authorization will remain in effect.
From the date of this Authorization until the:As long as I am under the care of Cabrillo Center for Rheumatic Disease		Date

Refusal to sign/right to revoke: I understand that signing this form is voluntary and that if I don’t sign, it will not affect the commencement, continuation or quality of my treatment at Cabrillo Center of Rheumatic Disease. If I change my mind, I understand that I can revoke this authorization at any time by providing a written notice of revocation to Cabrillo Center for Rheumatic Disease. The revocation will be effective immediately upon my health care provider’s receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.
I voluntarily authorize the disclosure of my health information to the recipient named above.I do NOT authorize the disclosure of my health information to the recipient named above.

Responsible Party Information (Only if Responsible Party is not the Patient)
FIRST NAME	MIDDLE NAME	LAST NAME

BILLING ADDRESS	CITY	STATE/ZIP

HOME PHONE	WORK PHONE	CELL PHONE

RELATIONSHIP TO PATIENT	SOCIAL SECURITY #	DRIVERS LICENSE #

Pharmacy Information
PHARMACY NAME

PHONE #	ADDRESS

Insurance Information
PRIMARY INSURANCE		EFFECTIVE DATE

INSURANCE PHONE	GROUP#

SUBSCRIBER’S NAME	SEX	BIRTHDATE

SUBSCRIBER’S EMPLOYER

RELATIONSHIP OF PATIENT TO SUBSCRIBER (select one)	IF TRICARE SPONSOR SSN# OR BENEFIT#
SelfSpouseChildOther

SECONDARY INSURANCE		EFFECTIVE DATE

INSURANCE PHONE	GROUP#

SUBSCRIBER’S NAME	SEX	BIRTHDATE

SUBSCRIBER’S EMPLOYER

RELATIONSHIP OF PATIENT TO SUBSCRIBER (select one)	IF TRICARE SPONSOR SSN# OR BENEFIT #
SelfSpouseChildOther

PRIMARY CARE INFORMATION
PRIMARY CARE PHYSICIAN	PHYSICIAN PHONE

PRIMARY CARE PHYSICIAN ADDRESS (IF KNOWN)	CITY	STATE	ZIP

EMERGENCY Information
EMERGENCY CONTACT PERSON		RELATIONSHIP TO PATIENT

HOME PHONE	WORK PHONE	CELL PHONE

Patient History Form
Date of first appointment:				Time of appointment:		Birthplace:

Name:

Birthdate:

Address:	Age:	Sex:	FM
	Home Phone:
	Work Phone:

MARITAL STATUS:	Never MarriedMarriedDivorcedSeparatedWidowed
Spouse/Significant Other:	Alive/Deceased/Age:	AliveDeceased	Age:		Major Illnesses:

EDUCATION (circle highest level attended):
Grade School:	789101112	College:	1234	Graduate School

Referred here by: (check one)	SelfFamilyFriendDoctorOther Health Professional
Name of person making referral:
The name of the physician providing your primary medical care:

Describe briefly your present symptoms:

Date symptoms began (approximate):

Diagnosis:

Previous treatment for this problem (include physical therapy, surgery and injections; medications to be listed later):

Please list the names of other practitioners you have seen for this problem:

RHEUMATOLOGIC (ARTHRITIS) HISTORY
At any time have you or a blood relative had any of the following? (check if “yes”)
Yourself		Relative Name/Relationship	Yourself		Relative Name/Relationship
	Arthritis (unknown type)			Lupus or SLE
	Osteoarthritis			Rheumatoid Arthritis
	Gout			Ankylosing Spondylitis
	Childhood Arthritis			Osteoporosis
OtherArthritisConditions:

Patient’s Name:

Date:

Physician Initials:

SYSTEMS REVIEW
As you review the following list, please check any problems, which have significantly affected you:
Date of last mammogram:		Date of last eye exam:	[DateEye placeholder "Date of last eye exam"]	Date of last chest x-ray:	[DateChest placeholder "Date of last chest x-ray"]

Constitutional	Gastrointestinal		Integumentary (skin and/or breast)
Recent weight gainRecent weight lossFatigueWeaknessFever	NauseaVomiting of blood or coffee ground materialStomach pain relieved by food or milkJaundiceIncreasing constipationPersistent diarrheaBlood in stoolsBlack stoolsHeartburn		Easy bruisingRednessRashHivesSun sensitive (sun allergy)TightnessNodules/bumpsHair lossColor changes of hands or feet in the cold
Eyes	Genitourinary		Neurological System
PainRednessLoss of visionDouble or blurred visionDrynessFeels like something in eyeItching eyes	Difficult urinationPain or burning on urinationBlood in urineCloudy, smoky urinePus in urineDischarge from penis/vaginaGetting up at night to pass urineVaginal drynessRash/ulcersSexual difficultiesProstate trouble		HeadachesDizzinessFaintingMuscle spasmLoss of consciousnessSensitivity or pain of hands and/or feetMemory lossNight sweats
Ears-Nose-Mouth-Throat	For Women Only:		Psychiatric
Ears-Nose-Mouth-Throat	Age when periods began: Periods regular? YESNO How many days apart? Date of last period? Date of last pap? Bleeding after menopause? YESNO Number of pregnancies? Number of miscarriages?		Psychiatric
Ringing in earsLoss of hearingNosebleedsLoss of smellDryness in noseRunny noseSore tongueBleeding gumsSores in mouthLoss of tasteDryness of mouthFrequent sore throatsHoarsenessDifficulty swallowing			Excessive worriesAnxietyEasily losing temperDepressionAgitationDifficulty falling asleepDifficulty staying asleep
Cardiovascular	Musculoskeletal		Endocrine
Chest PainIrregular heart beatSudden changes in heart beatHigh blood pressureHeart murmurs	Morning stiffnessJoint painMuscle weaknessMuscle tendernessJoint swelling	"Lasting how long?"	Excessive thirst
Respiratory	List joints affected in the last 6 mos.		Hematologic/Lymphatic
Shortness of breathDifficulty breathing at nightSwollen legs or feetCoughCoughing of bloodWheezing (asthma)			Swollen glandsTender glandsAnemiaBleeding tendencyTransfusion/whenAllergic/ImmunologicFrequent sneezingIncreased susceptibility to infection

			Allergic/Immunologic
			Frequent sneezingIncreased susceptibility to infection

Patient’s Name:

Date:

Physician Initials:

SOCIAL HISTORY		PAST MEDICAL HISTORY
Do you drink caffeinated beverages?	YESNO	Do you now have or have you ever had: (check if “yes)
Cups/glasses per day?		CancerGoiterCataractsNervous breakdownBad headachesKidney diseaseAnemiaEmphysema	Heart problemsLeukemiaDiabetesStomach ulcersJaundicePneumoniaHIV/AIDSGlaucoma	AsthmaStrokeEpilepsyRheumatic feverColitisPsoriasisHigh Blood PressureTuberculosis
Do you smoke?	YESNO Past – How long ago?	Other significant illness (please list)
Do you drink alcohol?	YESNO Past – How long ago?
Do you drink alcohol?	YESNO Past – How long ago?
Has anyone ever told you to cut down on your drinking?	YESNO	Natural or Alternative Therapies (chiropractic, magnets, massage, overthe-counter preparations, etc.)
Do you use drugs for reasons that are not medical?	YESNO
If yes, please list:
Do you exercise regularly?	YESNO
Type:
Amount per week
How many hours of sleep do you get at night?
Do you get enough sleep at night?	YESNO
Do you wake up feeling rested?	YESNO

PREVIOUS SURGERIES
Type		Year	Reason




Any previous fractures?	YESNO	Describe:
Any other serious injuries?	YESNO	Describe

FAMILY HISTORY
	IF LIVING		IF DECEASED
	Age	Health	Age at Death	Cause
Father
Mother

Number of siblings		Number living
Number of children		Number living

Health of children

Do you know any blood relative who has or had: (check and give relationship)
Cancer	Heart disease	Rheumatic fever	Tuberculosis
Leukemia	High blood pressure	Epilepsy	Diabetes
Stroke	Bleeding tendency	Asthma	Goiter
Colitis	Alcoholism	Psoriasis

Patient’s Name:

Date:

Physician Initials:

MEDICATIONS
Drug allergies:	YESNO	If yes, please list:

PRESENT MEDICATIONS: (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.)
Name of Drug	Dose (include strength & number of pills per day)	How long have you taken this medication	Please check: Helped?
Name of Drug	Dose (include strength & number of pills per day)	How long have you taken this medication	A Lot	Some	Not At All
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

PAST MEDICATIONS: Please review this list of “arthritis” medications. As accurately as possible, try to remember which medications you have taken, how long you were taking the medication, the results of taking the medication and list any reactions you may have had. Record your comments in the spaces provided.
Drug names/Dose	Length of time	Please check: Helped?			Reactions
Drug names/Dose	Length of time	A Lot	Some	Not At All	Reactions
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Check any you have taken in the past
FlurbiprofenDiclofenac + misoprostilAspirin (including coated aspirin)CelecoxibSulindacOxaprozin	SalsalateDiflunisalPiroxicamIndomethacinEtodolacMeclofenamateIbuprofen			FenoprofenNaproxenKetoprofenTolmetinCholine magnesium trisalcylateDiclofenac

Pain Relievers

Acetaminophen
Codeine
Propoxyphene
Other:
Other:
Osteoporosis Medications
Estrogen
Alendronate
Etidronate
Raloxifene
Fluoride
Calcitonin injection or nasal
Calcitonin injection or nasal
Gout Medications
Probenecid
Colchicine
Allopurinol
Uloric
Krystexxa
Other:

Patient’s Name:

Date:

Physician Initials:


PAST MEDICATIONS: Continued
Drug names/Dose	Length of time	Please check: Helped?			Reactions
Drug names/Dose	Length of time	A Lot	Some	Not At All	Reactions
Disease Modifying Antirheumatic Drugs (DMArDs)
Certolizumab
Golimumab
Hydroxychloriquine
Penicillamine
Methotrexate
Azathioprine
Sulfasalazine
Quinacrine
Cyclophosphamide
Cyclosporine A
Etanercept
Infliximab (Remicade)
Tocilizumab
Arava
Humira
Enbrel
Cymzia
Simponi
Orencia
Rituxan
Actemra
Kevzara
Xeljanz
Olumiant
Rinvoq
Stelara
Tremfya
Skyrizi
Cosentyx
Taltz
Others
Tamoxifen
Tiludronate
Cortisone/Prednisone
Hyaluronan
Herbal or Nutritional Supplements

Please list supplements:


Have you participated in any clinical trials for new medications?	YESNO
If yes, list:

Patient’s Name:

Date:

Physician Initials:

ACTIVITIES OF DAILY LIVING
Do you have stairs to climb?	YESNo	If yes, how many?
How many people in household?		Relationship and age of each
Who does most of the housework?		Who does most of the shopping?	Who does most of the yard work?

On the scale below, circle a number which best describes your situation; Most of the time, I function…

VERY POORLYPOORLYOKWELLVERY WELL

Because of health problems, do you have difficulty: (Please check the appropriate response for each question.)
Using your hands to grasp small objects? (buttons, toothbrush, pencil, etc.)	UsuallySometimesNo
Walking?	UsuallySometimesNo
Climbing stairs?	UsuallySometimesNo
Descending stairs?	UsuallySometimesNo
Sitting down?	UsuallySometimesNo
Getting up from chair?	UsuallySometimesNo
Touching your feet while seated?	UsuallySometimesNo
Reaching behind your back?	UsuallySometimesNo
Reaching behind your head?	UsuallySometimesNo
Dressing yourself?	UsuallySometimesNo
Going to sleep?	UsuallySometimesNo
Staying asleep due to pain?	UsuallySometimesNo
Obtaining restful sleep?	UsuallySometimesNo
Bathing?	UsuallySometimesNo
Eating?	UsuallySometimesNo
Working?	UsuallySometimesNo
Getting along with family members	UsuallySometimesNo
In your sexual relationship?	UsuallySometimesNo
Engaging in leisure time activities?	UsuallySometimesNo
With morning stiffness	UsuallySometimesNo
Do you use a cane, crutches, walker or wheelchair? (check one)	canecrutcheswalkerwheelchair
What is the hardest thing for you to do?
Are you receiving disability?	YESNo
Are you applying for disability?	YESNo
Do you have a medically related lawsuit pending?	YESNo

Patient’s Name:

Date:

Physician Initials:


Are you interested in learning about our clinical trials?



	Yes, please contact me about ongoing studiesNo, I am NOT interested

Cabrillo Center for Rheumatic Disease
1420 Ocotillo Dr, Ste B
El Centro, CA 92243
Phone: 760-309-1288 | Fax: 760-970-4270

New Patient Packet ⸻ El Centro

Are you interested in learning about our clinical trials?

Yes, please contact me about ongoing studiesNo, I am NOT interested

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New Patient Packet – El Centro

New Patient Packet ⸻ El Centro

Are you interested in learning about our clinical trials?

Yes, please contact me about ongoing studiesNo, I am NOT interested

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