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Fehmida Zahabi, M.D
6300 Stonewood Dr. Suite 412 Plano, TX 75024
PATIENT INFORMATION (Please Write the information about the patient here.)
Patient's Name (First, Middle Initial, Last) Date of Birth
Patient's Address (Number, Street, Apt.) Home Phone(include area code)
City
StateZipcode
Work Phone(include area code)
Age Sex(Male or Female) Marital Status Social Security Number Driver's License Number
Employer Referring Doctor
Complete the Information below about the policyholder of the primary insurance:
Policyholder's Name (First, Middle Initial, Last) Date of Birth
Policyholder's Address (if same as patient's address, write "SAME") Home Phone(include area code)
City
StateZipcode
Work Phone(include area code)
Employer Social Security Number
Relationship to Patient: Spouse Parent Other
Complete the Information below about the policyholder of the secondary insurance:
Policyholder's Name (First, Middle Initial, Last) Date of Birth
Policyholder's Address (if same as patient's address, write "SAME") Home Phone(include area code)
City
StateZipcode
Work Phone(include area code)
Employer Social Security Number
Relationship to the Patient: Spouse Parent Other
Please Complete the Referring Phsyician Information:
Physician Name: Practice Name:
Phone # :
Today's Date SIGNATURE (Patient, or parent if under 18 years of age)
6300 Stonewood Dr. Suite 412 Plano, TX 75024
Emergency Contact
In case of an emergency, please list someone living at residence other than those listed above:
Name Phone
Address Relationship
City State Zipcode

Please remember that Insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for the payment. Some companies pay fixed allowances for the certain procedures, and others pay a percentage of the charge. It is your repsonsibility to pay any deductive amount, co-insurance, or any other balance not paid for by your insurance.

IN ORDER TO CONTROL YOUR COST OF BILLINGS, WE REQUEST THAT OUR CHARGES FOR OFFICE VISITS BE PAID AT THE CONCLUSION OF EACH VISIT.

If this account is assigned to an attorney for collection and/or suit, the practice shall be entitled to reasonable attorney's fees and costs of collection. I authorize the release of any information necessary to determine liablity for payment and to obtain reimbursement on any claim.
I request that payment of authorized benefits be made on my behalf. I assign the benefits to which I am entitled including medicare, private insurance and other health plans payable to the practice named on th top of this form.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.
I understand that I am financially responsible for all charges whether or not paid by said insurance.

Today's Date SIGNATURE (Patient, or parent if under 18 years of age)
6300 Stonewood Dr. Suite 412 Plano, TX 75024
Texas Rheumatology Care Notice of Privacy Practices
Effective Date: April 14, 2003

This notice describes how medical information about you may be used and disclosed and how you can get access to this informatin. Please review it carefully.

We understand that medical information about you is personal and we are committed to protecting it. Texas Rheumatology Care is required by law to maintain the privacy of your health information, to follow the terms of this notice, and to provide you with this Notice of our legal duties and privacy practices with respect to your health information.

We may use or disclose your information:

We may also disclose your health information:

Except as described in this Notice, Texas Rheumatology Care will not use or disclose your health
information without your written authorization. If you do authorize Texas Rheumatology Care to disclose
your health information, you may revoke your authorization in writing at any time.

You have the Following Rights with Respect to your Health Information:

Texas Rheumatology Care Reserves the right to change this Notice. If we change our Notice, you may obtain a copy of the revised Notice by request. To file a complaint, please contact: HIPPA Coordinator, 6300 Stonewood Dr. #412, Plano, TX 75204

By signing below, I acknowledge that I have received Texas Rheumatology Care's Privacy Notice:


Signature of Patient or Authorized Representative Date



Notice of Privacy Practices
6300 Stonewood Dr. Suite 412 Plano, TX 75024
Bone Density Patient Questionnaire
Name(print): Date:
Is there a chance that you might be pregnant?    Yes   No
Have you had a barlum X-ray in the last weeks?     Yes   No
Have you had a nuclear medicine scan or injection of an X-ray dye in the last week?     Yes   No
If you answer yes to any of the above, speak to our receptionist right away.
Height:       Weight:       Date of Birth:
Do you have any metal in spine and/or hips?     Yes   No
Have you ever broken or fractured a bone?     Yes   No
Do you have times when you fall for no specific reason?     Yes   No
Have you ever been told that you have osteopenia or osteoporosis(significant bone loss)?     Yes   No
Do you take medicine for osteopenia or osteoporosis?     Yes   No
Do you have family history of osteoporosis?     Yes   No
Have you lost height(become any shorter)     Yes   No
Have you had a recent weight change?     Yes   No
Do you take calcium pills?    Yes  No     Do you take vitamin D or multi-vitamin?    Yes  No
Do you take medicine to control seizures, epilepsy, or convulsions?     Yes   No
Do you take steriods for chronic arthirtis and/or chronic asthma?     Yes   No
Do you take medicine for thyroid problems?     Yes   No
Do you have any kind of intestinal problem such as Crohn's Disease or Ulcerative Colitics?     Yes   No
Have you had renal(kidney) failure?     Yes   No     If so, are you on dialysis?
Do you consume beverages with alcohol?     Yes   No     If so, how many per day?
Do you smoke cigarettes?     Yes   No     Have you ever smoked cigarettes?
Do you take birth control or any type of estrogen?     Yes   No
Have you had a hysterectomy?    Yes   No       Are you in menopause?    Yes   No
Are you on hormone replacement therapy?     Yes   No
Patient Signature Here:
Fehmida Zahabi, M.D
6300 Stonewood Dr. Suite 412 Plano, TX 75024

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (PAPER, ORAL AND ELECTRONIC)

PATIENT'S NAME:

SS No:

ADDRESS :

DOB :

                

REQUEST DATE :

I AUTHORIZE DR.  

ADDRESS :

TEL:

                

FAX:

TO RELEASE INFORMATION TO DR. FEHMIDA ZAHABI, M.D.
THE PURPOSE OF THIS AUTHORIZATION IS:

INVESTIGATION/ASSESSMENT/CASE PLANNING
FURTHER MEDICAL CARE
CHANGING PHYSICIANS
CREATING HEALTH INFORMATION FOR DISCLOSURE TO A THIRD PARTY
OTHER

I AUTHORIZE RELEASE OF THE FOLLOWING:

ENTIRE RECORD
MEDICAL HISTORY ,EXAM REPORTS
SURGICAL REPORTS
TREATMENT AND TEST
HOSPITAL RECORDS FROM / / TO / /
LABORATORY REPORTS X-RAY REPORTS MR/DD RECORDS
OTHER



IN COMPLIANCE WITH THE STATE AND /FEDERAL LAWS WHICH REQUIRE SPECIAL
PERMISSION TO OBTAIN PRIVILEGED INFORMATION, PLEASE RELEASE THE FOLLOWING
RECORDS:



 
PATIENT OR AUTHORIZED REPRESENTATIVE
SIGNATURE
  DATE

THIS AUTHORIZATION EXPIRES ON . IF I DO NOT SPECIFY AN EXPIRATION DATE THIS AUTHORIZATION EXPIRES WITHIN SIX MONTHS FROM THE DATE IT WAS SIGNED.

Fehmida Zahabi, M.D
6300 Stonewood Dr. Suite 412 Plano, TX 75024
Phone:469-467-2478
Fax:469-467-8146


Thank you for choosing our office. The following information may help answer some questions you may have after your first visit and future visits.

You will receive notification of all test results ordered by Dr. Zahabi or Mrs. Landon within 10 days of the test. If after 10 days you have not heard from us by phone or letter, please contact us at that time.

Our office telphone number is (469)467-2478. Our staff answers the phone Monday thru Thursday, from 8:30 a.m. to 5:30 p.m. We ask that all non-emergency calls be made during this time period.

Please remember that our phone is not answered after hours or on Friday, Saturday or Sunday. If you have a situation and need to contact our office during non-office hours, please call (469)467-2478 and leave a message when prompted. Your call will be returned the following business day.

Patients with medical emergency should go directly to the nearest hospital or emergency care facility. The ER doctor can contact the on-call physician.

For all non rheumatologic emergencies, please contact your individual primary care physician. If you do not have one please contact your nearest urgent care facility.

For medcial records and forms completion, their will be a $25 charge. Please allow 2 weeks for processing.


PRESCRIPTION REFILLS

If you need a prescription refilled, please contact the pharmacy that dispensed the medication. Even if the pharmacy indicated that no refills are remaining, in most cases we will fill the prescription after the pharmacy contacts our office. To ensure that you do not go without medication, please contact your pharmacy for refills atleast 48 hours before you will need your medication.

For all hand written prescriptions please allow 48 hours before the medication is needed.


There may be times when your medical condition requires hospitalization. Although Dr. Zahabi has consultation privileges at Richardson Regional Hospital and Medical City Dallas, she does not admit to the hospital. If necessary she will refer you to your primary care physician or hospitalist who will care for you while you are hospitalized. During your hospital stay your primary hospitalist will update Dr. Zahabi about your condition or, at your doctor's request; Dr.Zahabi will be an active participant in your care while you are hospitalized.

Please give a 24 hours notice for all appointment cancellations, without a cancellation call you are subject to a $40 charge that your insurance will not cover.

Signature Date

Fehmida Zahabi, MD
Andrea Landon, APN
Patient History Form
Date of first appointment://   Time of appointment:   Birthplace:
Month Day Year
Name:  Birthdate://
LAST FIRST MIDDLEINITIAL MAIDENMonthDayYear
Address:     Age: Sex: F  M
  STREETAPT#  
 Telephone: Home
CityStateZip Work
MARITAL STATUS:Never MarriedMarriedDivorcedSeparatedWidowed
Spouse/Significant Other: Alive/AgeDeceased/AgeMajor Illness
EDUCATION(circle highest level attended):
Grade School 7 8 9 10 11 12   College 1 2 3 4   Graduate School
Occupation  Number of hours worked/average per week
Referred here by:(check one)SelfFamilyFriendDoctor Other Health Professional
Name of the person making referral:
The name of the physician providing your primary medical care:
Do you have an orthopedic surgeon?YesNoIf yes, Name:
Describe briefly your present symptoms:
Date symptoms began (approximate):
Diagnosis:
Previous treatment for this problem (include physical therapy, surgery and injections; medication 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
Other arthritis conditions:
Patient's Name   Date   Physician Initials

Fehmida Zahabi, M.D
6300 Stonewood Dr. Suite 412 Plano, TX 75024
SYSTEM REVIEW
As you review the following list, please check any of those problems, which have significantly affected you.
Date of last mammogram//     Date of last eye exam//     Date of last chest x-ray//
Date of last Tuberculosis Test //    Date of last bone densitometry //
Constitutional Gastrointestinal Integumentary (skin and/or breast)
Recent weight gain
        amount
Recent weight loss
        amount
Fatigue
Weakness
Fever
Eyes
Pain
Redness
Loss of vision
Double or blurred vision
Dryness
Feels like something in eye
Itching eyes
Ears-Nose-Mouth-Throat
Ringing in ears
Loss of hearing
Nosebleeds
Loss of smell
Dryness in nose
Runny nose
Sore tongue
Bleeding gums
Sores in mouth
Loss of taste
Dryness of mouth
Frequent sore throats
Hoarseness
Difficulty in swallowing
Cardiovascular
Pain in chest
Irregular heart beat
Suddent changes in heart beat
High blood pressure
Heart murmurs
Respiratory
Shortness of breath
Difficulty in breathing at night
Swollen legs or feet
Cough
Coughing of blood
Wheezing (asthma)
Nausea
Vomiting of blood or coffee ground material
Stomach pain relieved by food or milk
Jaundice
Increasing constipation
Persistent diarrhea
Blood in stools
Black stools
Heartbum
Genitourinary
Difficult urination
Pain or burning on urination
Blood in urine
Cloudy: "smoky" urine
Pus in urine
Discharge from penis/vagina
Getting up at night to pass urine
Vaginal dryness
Rash/ulcers
Sexual difficulties
Prostate trouble
For women only:
Age when periods began:
Periods regular? Yes No
How many days apart?
Date of last period?//
Date of last pap?//
Bleeding after menopause Yes No
Number of pragnancies?
Number of miscarriages?
Musculoskeletal
Morning stiffness
       Lasting how long?
       MinutesHours
Joint pain
Muscle weakness
Muscle tenderness
Joint swelling

     List joints affected in last 6 mons.
     
     
     
     
     
Easy bruising
Redness
Rash
Hives
Sun sensitive(sun allergy)
Tightness
Nodules/bumps
Hair loss
Color changes of hands or feet in the cold
Neurological System
Headaches
Dizziness
Fainting
Muscle spasm
Loss of consciousness
Sensitivity or pain of hands and/or feet
Memory loss
Night sweats
Psychiatric
Excessive worries
Anxiety
Easily losing temper
Depression
Agitation
Difficulty falling asleep
Difficulty staying asleep
Endocrine
Excessive thirst
Hematologic/Lymphatic
Swollen glands
Tender glands
Anemia
Bleeding tendency
Transfusion/when
Allergic/Immunologic
Frequent sneezing
Increased suspectibility to infection
Patient's Name   Date   Physician Initials

Fehmida Zahabi, M.D
6300 Stonewood Dr. Suite 412 Plano, TX 75024
ACTIVITIES OF DAILY LIVING
Do you have stairs to climb? Yes  No   If yes how many?
How many people in household? Relationship and age of each
Who do 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
POORLY
POORLY
OK
WELL
VERY
WELL
Because of health problems, do you have difficulty:
(Please tick the appropriate reason for each question.)
  Usually Sometimes No
Using your hands to grasp small objects?(buttons, toothbrush, pencil, etc.).....................
Walking?............................................................................................................................
Climbing Stairs?..................................................................................................................
Descending Stairs?.............................................................................................................
Sitting down?.....................................................................................................................
Getting up from chair?.......................................................................................................
Touching your feet while seated? ....................................................................................
Reaching behind your back? ............................................................................................
Reaching behind your head?.............................................................................................
Dressing yourself?.............................................................................................................
Going to sleep?.................................................................................................................
Staying asleep due to pain?.............................................................................................
Obtaining restful sleep?....................................................................................................
Bathing?............................................................................................................................
Eating?..............................................................................................................................
Working?...........................................................................................................................
Getting along with family members?..................................................................................
In your sexual relationship?...............................................................................................
Engaging in leisure time activities?....................................................................................
With morning stiffness?......................................................................................................
Do you use a cane, crutches, as walker or a wheelchair?(circle one).................................
What is the hardest thing for you to do?
Are you receiving disability?................................................................................................             Yes                 No
Are you applying for disability?............................................................................................             Yes                 No
Do you have a medically related lawsuit pending? ................................................................             Yes                 No
Patient's Name   Date   Physician Initials

Fehmida Zahabi, M.D
6300 Stonewood Dr. Suite 412 Plano, TX 75024
SOCIAL HISTORY FORM
SOCIAL HISTORY
Do you drink caffeinated beverages?
Cups/glasses per day?
Do you smoke? Yes No Past - How long ago?
Do you Drink alchohol? Yes No Number per week
Has anyone ever told you to cut down on your drinking?
Yes  No
Do you use drugs for reasons that are not medical?Yes No
If yes, please list:
Do you exercise regularly? Yes  No
Type
Amount per week
How many hours of sleep do you get at night?
Do you get enough sleep at night?    Yes    No
Do you wake up feeling rested?         Yes    No
PAST MEDICAL HISTORY
Do you now or have you ever had:(check if "yes")
Cancer Heart problems Asthma
Goiter Leukemia Stroke
Cataracts Diabetes Eplilepsy
Nervous breakdown Stomach ulcers Rheumatic fever
Bad headaches Jaundice Colitis
Kidney disease Pneumonia Psoriasis
Anemia HIV/AIDS High blood pressure
Emphysema Glaucoma Tuberculosis
Othe significant illness (please list)
Natural or Alternative Therapies (chiropractic, magnets, message, over-the-counter preperations, etc)
Previous Operations
Type Year Reason
1.
2.
3.
4.
5.
6.
7.
Any previous fractures?   No     Yes         Describe:
Any previous serious injuries?   No     Yes         Describe:
FAMILY HISTORY
IF LIVING

Age Health
IF DECEASED

Age of Death Cause
Father
Mother
Number of siblings Number living Number Deceased  
Number of children Number living Number Deceased List ages of each
Health of children:
Do you know any of blood relative who has or had:(check and give relationship)
Cancer Heart Disease Rheumatic fever Tuberculosis
Leukemia High blood pressure Epilepsy Diabetes
Stroke Bleeding tendancy Asthma Goiter
Colitis Alchoholism Psoriasis  
Patient's Name   Date   Physician Initials

Fehmida Zahabi, M.D
6300 Stonewood Dr. Suite 412 Plano, TX 75024
MEDICATIONS
Drug Allergies:     No   Yes      To what?
Type of reaction:
PRESENT MEDICATIONS(List any medications you are taking, including such items as aspirin, vitamins, lexatives, calcium and othe suppliments, etc.)
Name of Drug Dose(including strength & number of pills per day) How long have you taken this medication Please check: Helped?
Alot 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 result of taking the medication and list any reactions you may have had. Record your comments in the spaces provided.
Drug names/Dosage Length of time Please check: Helped? AlotSomeNot At All Reactions
Non-Steroid Anti-Inflammatory Drugs (NSAIDs)
Circle any you have in the past
Ansaid(flurbiprofen) Arthrotec(diclofenac+misoprostil) Aspirin(including coated aspirin) Celebrex(celecoxib)
Daypro(oxaprozin) Disalcid(salsalate) Dolobid(diflunisal) Feldene(proxicam)Indocin(indomethacin) Lodine(etodolac)
Meclomen(meclofenamate) Motrin/Rufen(ibuprofen) Nalfon(fenoprofen) Naprosyn(naproxen) Oruvail(ketoprofen)
Tolectin(tolmetin) Tilisate(choline magnesium trisalicylate) Vioxx(rofecoxib) Voltaren(diclofenac) Clionoril(sulindac)
Pain Relievers
Acetaminophen(Tylenol)
Codeine(vicodin, Tylenol3)
Propoxyphene(Darvon/Darvocet)
Other:
Other:
Disease Modifying Antirheumatic Drugs(DMARDS)
Auranofin, gold pills(Ridaura)
Gold Shots (Myochrysine or Solganol)
Hydroxycholoroquine (Plaquenil)
Penicillamine (Cuprimine or Depen)
Methotrexate (Rheumatrex)
Azathioprine(Imuran)
Sulfasalazine (Azulfidine)
Quinacrine (Atabrine)
Cyclophosphamide (Cytoxan)
Cyclosporine A (Sanddimune or Neoral)
Etanercept (Enbrel)
Infliximab (Remicade)
Prosobra Column
Other:
Other:
Patient's Name   Date   Physician Initials
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