환자정보 (PATIENT INFORMATION) REGISTRATION FORM PLEASE PRINT 성 (Last Name) / 이름 (First Name) / Middle Name 생년월일 (DOB: Month/Day/Year) 성별 (Sex) 보호자이름 (Name of Guardian) / / 환자와의관계 (Relationship) 남자 (M) 여자 (F) 부 (Father) 모 (Mother) 친척 (Relative) 친구 (Friend) 주소 (Address) 시 (City) 주 (State) 우편번호 (Zip) 전화번호 (Phone) 집 (Home) 직장 (Work) 휴대폰 (Cell) 응급시연락처 (Emergency Contact Name) 관계 (Relationship) 전화 (Phone) 이메일주소 (Email Address) 소설번호 (Social Security Number) 결혼관계 (Marital Status) 미혼 (Single) 기혼 (Married) 이혼 (Divorced) 미망인 (Widow) 직장이름 / 주소 (Employer Name / Address) 학생시신분 (Student Status) Full Time Part Time 인종 (Race) Black/African American Asian Caucasian Hispanic or Latino Other (Please Specify: ) 집에서사용하는언어 (Primary Language Spoken in the Home) English Spanish Korean Other (please define: ) 참전용사 (Veteran) Yes No 흡연여부 (Smoker) Yes No 병원을방문하신이유 (Reason to See the Doctor): 다음사항을정확히기입하여주십시오. 지난 21 일동안미국외나라를방문한적이있습니까? (Have you traveled outside the United States within the past 21 days?) 네 (Yes) / 아니오 (No) 방문한나라 (Where): 최근에미국외나라를방문시아픈사람과접촉한적이있습니까? (Have you recently been exposed to someone ill who has traveled outside the United States?) 네 (Yes) / 아니오 (No) 열이 101.5 F 를넘어간적이있습니까? (Has you had a fever of 101.5 F or greater?) 네 (Yes) / 아니오 (No) Print Name: Signature: Date:
PATIENT HEALTH QUESTIONNAIRE (pg 1/2) PLEASE PRINT 성 (Last Name) / 이름 (First Name) / Middle Name 생년월일 (DOB: Month/Day/Year) / / 언제마지막으로파상풍주사를맞았습니까? (When was your last Tetanus Shot) 올해독감주사를맞았습니까? (Have you had the flu shot this year?) 예 (Yes) 아니오 (No) 언제마지막으로병원을방문하셨습니까? (Last doctor s visit) 의사이름 (Doctor s Name): 병력 (Medical History) 해당사항을모두체크하세요 어릴적겪었던병 (Childhood Illness): 류마티스성열 (Rheumatic fever) 볼거리 (Mumps) 성홍열 (Scarlet fever) 수두 (Chicken pox) 소아마비 (Polio) 홍역 (Measles) 병력 : 당뇨병 (Diabetes Mellitus) 천식 (Asthma) 고혈압 (Hypertension) 심장병 (Heart Disease) 녹내장 (Glaucoma) 편두통 (Migraine) 궤양 (Ulcers) 고콜레스테롤 (High Cholesterol) 뇌졸증 (Stroke) 결핵 (Tuberculosis) 신장병 (Kidney Disease) 암 (Cancer) 우울증 (Depression) 관절염 (Arthritis) 갑상선질환 (Thyroid Disease) 빈혈 (Anemia) 골다공증 (Osteoporosis) 알코올중독 (Alcoholism) 발작경련 (Seizures) 정신병 (Mental Illness) 간염 (Hepatitis) 이외병명이있으시면모두나열해주세요 (Other): 약에부작용있으시면모두나열해주세요 (Drug Allergies): 지금복용하고계신약들을모두나열해주세요 (Current Medications including non-prescription medications and supplements): 입원경력 (Hospitalizations): 수술경력 (Surgeries): Social History 직업 (Occupation): 주당근무시간 (Hours per week): 직업만족도 (Satisfied with job): 상 중 하 주량 (Alcohol): drinks per week 커피 / 차 (Coffee/Tea): cups per day 담배 (Tabacco): Smoking: cigarettes per day # Years: Year quit: Chewing: cans per week # Years: Year quit: Recreational drugs 사용여부 : 특별한식이요법을하고계십니까? 운동은규칙적으로하고계십니까? 가족병력 (Family History) F: 아버지 M: 어머니 S: 형제자매 C: 자녀 R: 다른친척 해당사항을모두체크하세요. 당뇨병 (Diabetes): F M S C R 알코올중독 (Alcoholism): F M S C R 심장병 (Heart Disease): F M S C R 천식 (Asthma): F M S C R 당뇨병 (Diabetes): F M S C R 빈혈 (Anemia): F M S C R 녹내장 (Glaucoma): F M S C R 갑상선질환 (Thyroid Disease): F M S C R 고혈압 (Hypertension): F M S C R 관절염 (Arthritis): F M S C R 고지혈증 (High Cholesterol): F M S C R 발작경련 (Seizures): F M S C R 골다공증 (Osteoporosis): F M S C R 뇌졸증 (Stroke): F M S C R 편두통 (Migraine): F M S C R 암 (Cancer): F M S C R 암명 (Caner Name):
PATIENT HEALTH QUESTIONNAIRE (pg 2/2) PLEASE PRINT 전체리뷰 (System Review): 최근 3 개월동안겪어왔던모든증상에대해체크하세요 (Check any of the following which you have had in the last 3 months) 일반사항 (General) 열 / 오한 (Fever/chills) 피로 (Fatigue) 위장계통 (Gastrointestinal) 알르레기 / 면역계통 (Allergies / Immune) 계절성알르레기 (Seasonal allergies) 만성알르레기 (Year round Allergies) 후각계통 (Nose) 청력계통 (Ears) 귀통증 (Ear pain) 귀먹먹함 (Popping pressure) 이명 (Ringing in ears) 귀염증 (Ear infectionsfrequent) 신경계 (Neurologic) 두통 (Headache) 어지럼증 (Dizziness) 간질 (Seizures) 무감각 (Numbness or tingling) 속쓰림 (Heartburn) 축농증 (Sinus trouble) 청력손실 (Hearing loss) (Muscle weakness) 멀미 / 구토 (Nausea / vomiting) 식욕감퇴 (Loss of appetite) 콧물흘림 (Runny nose) 어지러움 (Dizziness) 기절 (Passing out) 몸무게감소 (Weight loss) 후두계통 (Throat) 눈계통 (Eyes) 피부계통 (Skin) 삼키기장애, 연하곤란 (Difficulty swallowing) 복통 (Abdominal painchronic) 후두통증 (Sore throat) 눈간지러움 (Eye irritation and itching) 두드러기 (Rash / hives) 쉰목소리 (Hoarseness) 눈통증 (Eye pain) 아토피성피부염 (Psoriasis / Eczema) 설사 (Diarrhea) 눈병 (Eye infections) 피부반점 (New moles) 혈변 (Bloody or Tarry stools) 호흡계통 (Respiratory) 시력변화 (Vision changes) 황달 (Jaundice) 기침 (Cough) 심장계 (Cardiac) 간염 (Hepatitis) 숨가쁨 (Shortness of breath) 혈액계통 (Hematology) 가슴통증 (Chest pain) 대장게실 (Diverticulosis) 천식 (Asthma / wheezing) 멍 (Bruising) 발목부종 (Swollen ankles) 대장염 (Colitis) 폐렴 (Pneumonia) 출혈 (Bleeding) 부정맥 (Irregular pulse) 기관기염 (Bronchitis) 수혈 (Blood transfusions lifetime) 임파선부종 (Enlarged lymph nodes) 도보시다리통증 (Leg pain when walking) 심잡음 (Heart murmur)
환자의료정보공개동의서 (Patient Preference Regarding Communication of Health Information) 건강보험의이전과책임에관한법률 (HIPAA) 에의거하여환자의프라이버시를보호하기위해서, 당사자이외 환자가지정한제 3 자 ( 가족인이나대리인 ) 에게환자본인의의료정보를접근혹은공개를허용할경우이 동의서에서명이필요합니다. 또한공개방식으로 NextMD 에서지정한연락정보에의해전화메세지, 메일통보, 이메일을선택할수있습니다. In order to better protect your privacy under HIPAA (Health Insurance Portability and Accountability Act), we have created this consent form for releasing medical information to family members and other people of choosing. This will also be used for consent to leave you detailed telephone messages at the mentioned phone numbers, mail your lab results to your home and also send secure email results to your personal email address once enrolled in NextMD. Many times we have patient s family members call requesting medical information and legally we are not allowed to release that information without the patient s written consent. The purpose of this document is to protect your privacy. 환자가족및대리인지정 (Communication to Family Members, Spouses or Other) 아래지정한사람에게나의조건과치료방법에관한예약, 질문등에관한의료정보를공유하는것을허락합니다. I, 본인이름 (Name) 생년월일 (DOB), hereby give my permission for the release of medical information regarding appointments and questions about my condition and treatments to the following person: 위에지정한가족, 친척, 또는대리인이외어떤분에게도본인의어떠한의료정보를접근혹은공유를허락치않은경우여기에 체크하시기바랍니다. (Check here if you do not give permission for additional family members, relatives or close personal friends to have access to any information regarding my medical condition(s).) NextMD 를통한의료정보교환 (Electronic Communication via NextMD (Secure Electronic Medical Records)) 네, NextMD 의 Patient Portal 을통하여의료정보를교환하기를원합니다. 검사결과와같은확인할정보가있을시에이메일로연락해드립니다. 이이메일에는보완이된웹사이트로접속할수도록링크가제공되어지며, 이링크를통해본인이정한 user name 과 password 로검사결과를인터넷에서확인하실수있습니다. 아래에본인이사용하고자하는이메일을적어주시기바랍니다. Email address: 아니오, NextMD 를통한인터넷상에서의료정보를교환하기를원하지않습니다. 이경우검사결과는예약을통해의사를직접만나서확인하시거나메일로결과를보내드릴수있습니다. 메일확인시최대 10 일시간이소요될수있습니다. 전화를통한의료정보교환 (Communication via the Telephone) 환자의료정보또는예약확인등을아래에있는전화번호의음성메세지로연락해드립니다. ( 회사 / 휴대폰 / 집전화 ) ( 회사 / 휴대폰 / 집전화 ) 동의서서명 (Consent and Agreement) 위의환자의료정보공개동의서에설명되어진가이드라인을잘이해하고동의합니다. 서명 ( Signature): 날짜 (Date):
환자의료정보공개동의서 (Financial Policy) 건강보험의이전과책임에관한법률 (HIPAA) 에의거하여환자의프라이버시를보호하기위해서