Dr. Balog's Practice

Frequently Asked Questions

Medical History Questionnaire

HISTORY
Please copy the page to a word processor, complete and save it and send it in an e-mail to ibalog@pol.net. Also, please print it, and bring the printed form to your next office visit.

Name:
Age:
E-mail address:

Marital status:
Lives with:
Religion:

Predominant hand:

Occupation:
All previous occupations:

Years in high school:
Years in college:
Degrees:

Date of birth:
Birthplace:

Father (age and health / conditions):
If deceased, age at death and cause of death:
Mother (age and health / conditions):
If deceased, age at death and cause of death:

Brother/sister (age and health / conditions):
If deceased, age at death and cause of death:

Spouse (age and health / conditions):
If deceased, age at death and cause of death:

Son/daughter: (age and health / conditions):
If deceased, age at death and cause of death:

Has any blood relative, or husband/wife ever had:
(Please indicate relationship and age at giagnosis)

High blood pressure:
Allergies:
Asthma:
Arthritis:
Glaucoma:
Cancer of breast:
Cancer of colon:
Cancer of prostate:
Cancer of ovaries:
Cancer of other organ:
Diabetes:
Tuberculosis:
Heart disease:
Stroke:
Epilepsy or seizures:
Alcohol abuse:
Substance abuse:
Depression or emotional problems:
Suicide:
Kidney trouble:
Birth defects:
Sickle cell anemia:
Mental retardation:

Date of last physical exam:
Physician:

SURGERIES / HOSPITALIZATIONS:
Year:
Reason:
Year:
Reason:
Current medications (with dose and frequency):
Any additional medication:

Weight now:
1 year ago:
Desired weight:

Alcoholic beverages (on average, per week):
Ever treated for alcoholism: «*»

Ever used
Marijuana:
Cocaine:
Heroin:
Other:
Ever treated for drug (illicit or prescription) dependency:

Use seat belts in car:
Use tobacco:
Cigarettes: pack/day
Cigars /day
Pipe:
Snuff:
Chewing tobacco:
Age when started to smoke:
Age stopped smoking:

Any special diet:
Exercise:
Type:
Frequency:
Distance or amount:

Date and result of last
Pap smear:
Mammogram:
Cholesterol:
ECG/treadmill:
Stool test for blood:
Sigmoidoscopy / colonoscopy:
Chest X-Ray:
Stomach X-Ray (Upper G.I. / gastroscopy):
Colon X-Ray (Barium enema):
Other X-Ray:

Have you ever had swelling or lumps of testicles:
Do you do regular testicular self exam:

Menstrual Hx if applicable
Age at onset:

DATE OF LAST PERIOD:

Cycle (from start to start): every (28) days
Usual duration of flow: days.
Flow is:
Pain or cramps:
Irregular periods:
Vaginal infections or frequent discharge:
Birth control pills:
IUD:
Any abnormal Pap smear:

DATE OF LAST PAP SMEAR: «*»

PREGNANCIES; Total number:
# of children born alive:
# of stillbirths:
# of premature births:
# of Cesarean sections:
# of miscarriages:
# of abortions:

IMMUNIZATIONS with year of most recent immunization:

Measles Mumps and Rubella::
Diphtheria and Tetanus:
Polio:
Influenza:
Hemophilus influenzae:
Pneumonia:
Hepatitis A:
Hepatitis B:

EXPOSURES:
Lead:
DES:
Asbestos:
Other (Chemicals, Noise, etc.):

ALLERGIES (with nature and severety of reaction)
Penicillin, Sulfa, other antibiotics:
Aspirin, Codeine, Morphine:
Any other medications:
Insect bites or stings:
Any foods:
Any other substance:

Do you consider yourself healthy:
Your greatest health problem:
Are you able to take care of yourself:

PERSONAL HISTORY: any of the items listed below apply to you ?
(PLEASE ELABORATE IF THE ANSWER IS "YES"):

Measles (10 day):
German Measles (3 day):
Mumps:
Chicken pox:
Whooping Cough:
Scarlet fever/Scarlatina:
Diphtheria:
Pneumonia:
Influenza:
Pleurisy:
Any eye disease, injury, impaired sight:
Any ear disease, injury, impaired hearing:
Any troubles with nose, sinuses, mouth, throat:
Problems with your teeth:
Rheumatic fever:
Rheumatism:
Any bone or joint disease:
Neuritis or neuralgia:
Bursitis, sciatica or lumbago:
Stiff, swollen or painful joints:
Polio or meningitis:
Bladder or kidney infection or stones:
Gonorrhea syphilis, or herpes genitalis:
Chlamydia or Venereal warts:
Anemia:
Yellow jaundice or hepatitis:
Tuberculosis:
Mononucleosis:
Diabetes:
Hypoglycemia:
High blood pressure:
Low blood pressure:
Cancer:
Food chemical or drug poisoning:
Received blood or plasma transfusions:
Broken or cracked bones:
Concussion or head injury:
Knocked unconscious:
Dislocations:
Severe lacerations, scars:
Recent sprains:
Frequent infections or boils:
Hay fever or asthma:
Hives:
Eczema:
Fainting spells:
Convulsions or seizures:
Frequent or severe headaches:
Dizziness:
Anxiety/tension:
Difficulty remembering or concentrating:
Difficulty sleeping:
Frequent crying spells:
Work or family problems:
Thoughts about committing suicide:
Nervous breakdown:
Paralysis or numbness:
Enlarged thyroid or goiter:
Enlarged glands:
Skin problems:
Recent change in appetite or eating habits:
Chest Pain or angina pectoris:
Spitting up of blood:
Night sweats:
Shortness of breath:
Palpitation or fluttering heart:
Heart murmur:
Swelling of hands, feet or ankles:
Extreme tiredness or weakness:
Varicose veins:
Albumin, sugar, blood or pus in urine:
Difficulty urinating:
Get up at night to urinate:
Abnormal thirst:
Stomach trouble or ulcer:
Colitis or other bowel disease:
Liver or gall bladder disease:
Hemorrhoids:
Rectal bleeding:
Constipation or diarrhea:
Black bowel movements:
Change in bowel or bladder habits:
Indigestion or difficulty swallowing:
Change in a wart or mole:
Hoarseness or cough:
Non-healing sores:
Lumps in breasts or elsewhere:
Unusual bleeding or discharge:
Tubal infections:
Sex is not satisfactory:

Payment Policies

ISTVAN BALOG, M.D.
McIntosh Family Medical Center
1299 GA Hwy 57, Townsend, GA 31331
(912)832-4495 Fax: (912)832-4852 E-mail:ibalog@pol.net
http://www.drbalog.yourmd.com

Payment Policy

Thank you for choosing us as your primary care provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

Insurance. We participate in many insurance plans, including Medicare. By federal law, we have to file claims for Medicare participants. As for all other insurance, including "privatized" Medicare, we file claims as a courtesy. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but do not have an up-to-date insurance card with online (readily) verifiable coverage / deductible information, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

Our policy is to charge for the time and effort, outside of the course of an office visit, to change medications (based not on medical considerations / necessity), and for the time and effort to comply with requests of insurers for prior approval of medications and procedures, which are perfectly reasonable, indicated, and thoroughly discussed during an office visit. Also, we are charging for the time and effort to replace lost, misplaced prescriptions, and for complying with unreasonable refill requests from automated pharmacy programs.

Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

Non-covered services. Please be aware that some - and perhaps all - of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you are responsible for the balance of a claim.

Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.

Nonpayment. If your account is over 45 days past due, we will send you a bill. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, you may be discharged from this practice. If this is to occur, you will be notified that you have 30 days to find alternative medical care. During that 30-day period, we will be able to treat you only under special circumstances.

Missed appointments. Our policy is to charge for missed appointments not canceled within a reasonable amount of time. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment. If you did not keep your appointment, please do not call or ask the pharmacist to call for refill of any medication; the return visits are scheduled to assure that the treatment plan is reasonable, the prescribed medications are working, and are not causing any harm. You have to be seen before new prescription can be written.

Our practice is committed to providing the best treatment to our patients. Our prices are based on the Medicare fee schedule; they are lower than the usual and customary charges for our area.

Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

I have read and understand the payment policy and agree to abide by its guidelines:

______________________________________ ___________________
Signature of patient or responsible party Date

Copyright © 2004 American Academy of Family Physicians..

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