JEFFREY DICKERSON

Pulmonologist

Medical Specialists of Helena

2525 Broadway Suite 200

Helena, MT. 59601

406‑457‑4343

fax # 406‑457 4344

 

Your appointment is scheduled for ____________________________ 

at _______________

 

You have been scheduled for a Pulmonology consultation. Please complete this medical history questionnaire BEFORE your scheduled appointment and bring it with you when you come. I feel this information is essential to a thorough evaluation, and its completion will allow us more time for a detailed discussion of your main problem. If you misplace this questionnaire please call our office for another copy. It may be necessary to reschedule your appointment if you do not have the Questionnaire completed when you arrive.

 

It is necessary that you have a primary physician to whom I will send your consultation report and who will provide long‑term follow up care. I am available for care during clinic hours and if you have questions or are experiencing some problems you would like to discuss, please call. After hours, holidays, and weekends you will need to contact your primary physician.

 

My office is located on the second floor of the new Maria Dean Medical Building in Suite 200 east of St. Peter's Hospital. I recommend that you use the north entrance facing Broadway, and take the elevator to second floor.

 

MARIA DEAN MEDICAL SPECIALISTS

2525 Broadway, Suite 200

Helena, Montana 59601

Fax: (406) 457‑4344

Ph.: (406) 457‑4343

 

□ Dr. Anderson   □ Dr. Dietz     □ Dr. Dickerson

 

□ Dr. Eden           □ Dr Snyder

 

Name:_______________________________________________________________________________

 

Who referred you? ______________________________________________________________________

 

Who is your family doctor? _______________________________________________________________

Please briefly describe why you are being seen today? _____________________________________
_________________________________________________________________________

 

Please briefly list any conditions or chronic illnesses you have (such as high blood pressure, diabetes, depres­sion, glaucoma, prostate problems, sleep disturbances, thyroid disease, lung disease,, high cholesterol, mental illness,

etc.,...): ______________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

 

 

Please list any major illness or surgeries that you have had? ______________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

 

Please list all of your current medications and dosage. This should include all prescription, and over‑the‑counter medications including vitamins. and herbal supplements: ________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

 

Are you taking blood thinner medications such as Coumadin or Heparin?                   O Yes   O No

 

 

 

 

 

 

 

 

Are you allergic to latex?                                 □ Yes □ No

Please list all drug allergies and reactions? ____________________________________________________

_____________________________________________________________________________________

 

 

Family History

 

Circle any of the illnesses or conditions, which have occurred in any blood relatives.

 

Cancer‑ Type of cancer:______________       Which family member? ________________________

Headaches                Depression                        Liver Disease                                    Diabetes

Stroke                       Tremors                            Heart Disease                                   Rheumatoid Arthritis

Alcohol/Drug Addiction                                   Epilepsy or Seizures                         High Blood Pressure

Brain Hemorrhage (or aneurysm)                      Disorders of Muscles or Nerves

 

Personal History

 

□ Single              □ Married                 □ Divorced                 □Widowed              □ # of Marriages ____

 

Level of Education: _________________________________________________________________________

 

□ Working   or    □ Retired     Most recent occupations: _____________________________________________

 

Are you presently receiving Workers Compensation or Social Security benefits because of a disability?

            □ Yes              □ No

 

If your problem is related to an injury or accident, are you represented by an attorney? □ Yes   □ No

 

If Yes; list the name of the attorney: ____________________________________________________________

 

Do you smoke? □ Yes             □ No              How many packs per day?  _________  How many years? ________

 

Do you chew tobacco?            □ Yes             □ No                 How much? ____________________________

 

Do you drink alcohol? □ Yes □ No     If Yes, on average how many drinks per week do you have? ___________

 

Do you use mood altering or addictive drugs? □ Yes □ No

 

If No, have you done so in the past? □ Yes □ No

 

Have you recently been under any significant or unusual family, marital, legal, job‑related or other stress?

Please describe: ___________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

 

 

HELENA MEDICAL SPECIALISTS

MARIA DEAN BUILDING

2525 BROADWAY

HELENA, MT 59601

 

CHARLES B. ANDERSON, M.D.                                                  KENNETH V. EDEN, M.D.

ADULT NEUROLOGY                                                                 GASTROENTEROLOGY

 

MARK DIETZ, M.D.                                                                    JEFFREY DICKERSON, M.D.

ADULT NEUROLOGY                                                                 PULMONOLOGY

 

ARTHUR SNYDER, M.D.

RHEUMATOLOGY

 

BILLING INFORMATION

 

IF YOU ARE COVERED BY MEDICAID

YOU MUST PRESENT YOUR CURRENT CARD AT EACH VISIT. YOUR PHYSICIAN HAS THE RIGHT TO REFUSE SERVICES IF YOU DO NOT HAVE YOUR CARD.

 

IF YOU ARE COVERED BY WORKER'S COMPENSATION

YOU MUST BRING YOUR CLAIM NUMBER, DATE OF INJURY, AND THE NAME OF THE WORKER'S COMPENSATION AGENCY. THIS INFORMATION CAN BE OBTAINED THROUGH YOUR EMPLOYER OR YOUR WORKER'S COMPENSATION AGENT. AS THE PATIENT RECEIVING SERVICES, YOU ARE ULTIMATELY RESPONSIBLE FOR PAYMENT SHOULD WORKER'S COMPENSATION COVERAGE BE DENIED.

 

IF YOU ARE COVERED BY MEDICARE OR OTHER PERSONAL INSURANCE PLANS

PLEASE BRING YOUR INSURANCE CARD AND ANY OTHER INFORMATION THAT MAY BE HELPFUL FOR OUR BILLING OFFICE.

 

OUR BILLING OFFICE WILL GLADLY SUBMIT YOUR CLAIM TO YOUR INSURANCE COMPANY, PROVIDED WE HAVE ALL THE NECESSARY INFORAMTION. IF YOU DO NOT HAVE ANY INSURANCE COVERAGE WE ASK THAT YOU CONTACT OUR BILLING OFFICE TO SET UP PAYMENT ARRANGEMENTS. IF YOU HAVE ANY QUESTIONS REGARDING THE ABOVE INFORMATION PLEASE CONTACT OUR OFFICE.

 

I UNDERSTAND THAT THE ABOVE INFORMATION IS NECESSARY IN ORDER TO PROCESS MY CLAIM.

 

SIGNATURE                                                                                      DATE