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Dr. Sandra Sessoms – New Patient

Dr. Sandra Sessoms - New Patient Rheumatology Questionnaire

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.
  • Chief Complaint

  • Past Medical History

    Please list all medical problems (high blood pressure, etc.) including serious childhood illnesses. Include the year of the diagnosis, the medications, and any complications.
  • Childhood

  • Medical ProblemDate of DiagnosisMedicationsComplications 
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  • Medical ProblemDate of DiagnosisMedicationsComplications 
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  • Surgical History

    Please include the hospital, location, date/reason for admission, and discharge date.
  • DateHospitalCityStateReason for HospitalizationDischarge Date 
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  • MedicationReaction 
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  • MedicationDosageHow OftenDuration 
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    Please indicate all medications you are currently taking, dosages, duration, and how often.
  • List Arthritis Medications

    Please indicate which medications you have been prescribed in the past and include dates wherever possible.
  • DosageHow OftenStart DateEnd DateDuration 
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  • DosageHow OftenStart DateEnd DateDuration 
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  • DosageHow OftenStart DateEnd DateDuration 
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  • DosageHow OftenStart DateEnd DateDuration 
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  • DosageHow OftenStart DateEnd DateDuration 
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  • DosageHow OftenStart DateEnd DateDuration 
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  • DosageHow OftenStart DateEnd DateDuration 
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  • FoodReactionHow Long 
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  • SubstanceReaction 
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  • Per DayPer WeekPer Month 
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  • Social History

  • If yes, please list the name of a relative, close friend, or significant other that may be contacted in case of an emergency.
  • SchoolDegreeGraduated 
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  • If yes, please list the name of a relative, close friend, or significant other that may be contacted in case of an emergency.
  • Family Health History

  • AliveCurrent HealthDeceasedAge at DeathCause of Death 
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  • AliveCurrent HealthDeceasedAge at DeathCause of Death 
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  • AliveCurrent HealthDeceasedAge at DeathCause of Death 
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  • AliveCurrent HealthDeceasedAge at DeathCause of Death 
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  • AliveCurrent HealthDeceasedAge at DeathCause of Death 
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  • AliveCurrent HealthDeceasedAge at DeathCause of Death 
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  • AliveCurrent HealthDeceasedAge at DeathCause of Death 
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  • AliveCurrent HealthDeceasedAge at DeathCause of Death 
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  • AliveCurrent HealthDeceasedAge at DeathCause of DeathHow Many Male?How Many Female? 
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  • Family History of Illness

    Have you or any of your family members ever had any of the following illnesses? Please indicate the type of illness and the gender of the family member afflicted.
  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • YesNoGenderRelationship 
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  • Health Problems Questionnaire

    Please mark "Yes" after each question, and add any comments you wish. You will be questioned further for each "Yes" answer. Please include current and recent problems only.
  • Skin, Hair, and Nails

  • Head

  • Eyes

  • Ears

  • Nose/Sinuses

  • Mouth/Throat

  • Neck

  • Heart, Lungs, Blood Vessels

  • Stomach and Intestines

  • Kidney and Bladder

  • Genital

  • Female Menstrual and Obstetrical History

  • PATIENT FINANCIAL CONTRACT WITH DR. SESSOMS

    Here at Dr. Sessoms' office, the doctor and staff are pleased to provide you with the utmost quality care. We feel your understanding of our financial policy is important to our professional relationship. Please feel free to ask if you have any questions regarding this financial policy.

    Dr. Sessoms is strictly a fee for service physician. We require full payment at the time of service. We will supply you with a copy of your itemized statement so that you may file for reimbursement with your insurance company. Should your insurance company require a more detailed description of service, please have them request it in writing. Insurance is a contact between you and your insurance company. We are not a party to your contract. We will not become involved in any disputes between you and your insurance company regarding "reasonable and customary" charges, non-covered charges, pre-existing conditions, or coordination of benefits other than to supply the factual information as necessary.
  • PLEASE INITIAL ALL THREE STATEMENTS:

  • MEDICARE WAIVER

    Dr. Sessoms is not a participating provider with Medicare and has opted out of the Medicare Program. Since Dr. Sessoms has not contracted to accept assignment for Medicare insurance, and has opted out of Medicare, neither she nor I shall file any claims from this office with Medicare, or with any participating Medicare supplemental insurance program, for current or future medical care. I have been informed by Dr. Sessoms' office that I have the right to obtain Medicare covered items and services from a physician/practitioner who has not opted out of Medicare.

    Dr. Sessoms' current opted out status is valid July 1, 2011 until June 30, 2013 and will be renewed for two years (July 1, 2013 until June 30, 2015). At that time, Dr. Sessoms will file another two year renewal of the opted out status. For those not currently Medicare patients, note this waiver will become effective on the first day of your Medicare coverage.
  • Tricare/Champus Patients

    I, as a Tricare/Champus patient, am aware there is a 115% balance billing limitation for all medical charges. I understand that services rendered by Dr. Sessoms could exceed the 115% balance billing limitation. I am willing to waive my rights under the Tricare/Champus Department of Defense Appropriations Act and agree to be responsible for the difference between the billed charge and the Tricare Maximum Allowable Charge.
  • PLEASE INITIAL BOTH STATEMENTS:

  • PATIENT AGREEMENT

    All Patients: I choose for Dr. Sessoms to treat my medical conditions with the agreement that I am willing to pay for all my charges and will be fully responsible for my financial medical obligations with Dr. Sessoms, for all present and future care. Any questions I may have had were answered and explained to me in full. I have read and understand this document in its entirety and here by agree to the terms stated in the document.

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