Iker Leycegui, M.D., P.A.

Past Medical History

Name:

DOB:

Hospitalization/Major Surgery/Reason for Admission

Hospital
Dates of Stay___
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Allergies:___________________________________________________________________________

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Ongoing Medical Issues: (Check any that you are currently experiencing or have recently experienced)
Weakness
Fatigue
Weight gain / loss
Change in appetite
Fever or chills
Night sweats
Hot flashes
Headaches
Easy bruising
Double vision
Decreased hearing
Dizziness or fainting
Congestive heart failure
Heart attack
Arrhythmia
Bladder infection
Tuberculosis
Diabetes
Glaucoma

Insomnia
Chronic sinusitis
Venereal disease
Arthritis
Sore throat
Kidney disease
Shortness of breath
Chest pain or discomfort
Swelling feet, hands, ankles
High blood pressure
Muscle spasm or pain
Seizures
Ulcer/ Heartburn
Hemorrhoids
Asthma
Hepatitis
Cancer: type:___________
Hernia

Palpitations
Aids or HIV
Difficulty swallowing
Heart Valve Problems
Nausea or Vomiting
Chronic diarrhea
Painful urination
Frequent urination
Blood in urine
Anxiety or Depression
Thyroid disease: high
Thyroid disease: low
Elevated cholesterol
Anemia
Hives or Eczema
Stroke
Polio

______________________________________________________________________
Family History: (Check any that a blood relative has had. Please indicate relatives relationship & age.)
Cancer____________________________
Tuberculosis________________________
Diabetes___________________________
Heart disease_______________________
High blood pressure__________________
Asthma____________________________
Drug or Alcoholism___________________
Anemia____________________________
Thyroid disease_____________________
High cholesterol_____________________

Glaucoma___________________________
Stroke______________________________
Epilepsy_____________________________
Gout________________________________
Bleeding Disorder_____________________
Lung disease_________________________
Mental illness_________________________
Migraine_____________________________
Ulcer________________________________
Kidney disease________________________

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Preventive Care: (Please indicate date of last test, procedure or exam)
Physical exam:___/___/___
Complete Bloodwork:___/___/___
Colonoscopy:___/___/___ polyps? yes no
Stress test/ catheterization:___/___/___
MALE ONLY:
FEMALE ONLY:
Rectal/ Prostate exam:___/___/___
Pap/Pelvic exam:___/___/___
PSA:___/___/___
Mammogram:___/___/___
Bone density:___/___/___
Name of GYN:__________________

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Social History: (Check only if yes and indicate how often; if daily, indicate how much per day)
Smoking
Daily:_____
Years:_____
Alcohol
Daily/Weekly/Monthly:_____
Recreational Drugs
If yes, which drug?_________________________
IV drugs at least once
Coffee
Daily:_____
Herbal Tea
Daily:_____
Exercise
Daily/Weekly/Monthly:_____

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Developmental History: (Check if you currently have or have had in the past)
Measles
Whooping cough
Smallpox
Other:_______

Mumps
Scarlet fever
Pneumonia

Chicken Pox
Diphtheria
Rheumatic fever

Pneumonia vaccine
Other:___________________

Tetanus vaccine

Flu vaccine

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Current Medications: (List all medications, including those without a doctors prescription)
Name:
Strength:
Frequency
.
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Medical History Statement:
To the best of my knowledge, the questions on this form have been accurately answered. It is my
responsibility to inform the doctors office of any changes in my medical history including, but not limited
to: allergies, conditions, medications, etc.
Signature of Patient/Guardian:___________________________________

Date:___/____/______

Patient Information
Name:___________________________ DOB:___/___/____ Age:_____ SS#:_____-______-________
Sex:

Male

Female

Phone (Home) :_____-_____-______

Phone (Mobile):____-____-_____ Phone (Work):____-___-____

Address:______________________
_______________________
_______________________

Email:______________________

Emergency Contact:
Name:______________________ Relationship:______________ Phone:____-____-____
Name:______________________ Relationship:______________ Phone:____-____-____
How were you referred to Dr Leycegui?
____________________________________________________________________________________

Insurance Information
Plan name:______________________
Subscriber name:_________________
Policy #_________________________
Group# (if applicable)______________
By providing your insurance information to the staff at Iker Leycegui, M.D., P.A., you are hereby
authorizing our staff and/or billing company to issue claims on your behalf.
Signature:________________________________

Date:____/____/____

______________________________________________________________________
Privacy Practices
My signature below verifies that I have received a copy of Iker Leycegui, M.D., P.A.s Notice of Privacy
Practices.
Signature:________________________________

Date:____/____/____

If you would like to authorize the physician and the physicians staff to discuss your medical information
with an authorized party other than your emergency contacts, please indicate below:
Name:_________________________
Name:_________________________
Name:_________________________

Relationship:_____________
Relationship:_____________
Relationship:_____________

______________________________________________________________________

Authorization for Release of Patient Health Information

Please indicate any physicians or health facilities which we may need to obtain records
from on your behalf.
Name:__________________________
SSN#______-_______-_________

DOB:__________

Release From:
________________________________
________________________________
________________________________
________________________________
Release all medical records (all notes/reports/labs/consultations)_______________
All medical records from dates:_________________
Other:_________________________

Release to:

Iker Leycegui, M.D., P.A.

145 Central Park West Ste 101
Port Saint Lucie, FL
34986
Phone: 772-873-1919
Fax: 772-873-1171

Signature of Patient / Guardian:_______________________

Date:____/____/_____