REVIVE HEALTH CENTER

4734 West Waco Drive- Waco, Texas 76710

Main (254) 230-8281 Fax (254) 366-1958
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

PATIENT ______________ , _____________________________ DOB _____

sL
ADDRESS ,

CITY
v STATE _______________ ZIP CODE ,

DATE OF SERVICE RECORDS FROM THROUGH

I, THE PATIENT REQUEST THAT MY MEDICAL INFORMATION BE RELEASED AS REQUESTED FROM.

PLEASE SEND TO:

4734 W. Waco Drive
Waco Tx. 76710
254-230-8281 fax#

ER notes / Radiology reports / Discharge summary/ lab reports / physician's orders/ Chart

Release of information is necessary for follow up care or referral

THE INFORMATION RELEASED IS FOR THE SOLE PURPOSE OF EVALUATION AND MANAGEMENT OF PATIENT CARE
AND MAY NOT BE PROVIDED IN WHOLE OR IN PART TO ANY OTHER PERSON, AGENCY, FACILITY, OR ORGANIZATION
EXCEPT TO THE ENTITY STATED ABOVE. THIS CONSENT WILL EXPIRE AFTER TWELVE (12) MONTHS AFI ____ ER THE DATE
OF THE SIGNATURE BELOW:

tx-- I ._ DATE SIGNED:

SIdNYA TURE OF PA TI NT / OR LE GAL GUARDIAN PATIENT

PRINT NAME OF PATIENT / OR LEGAL GUARDIAN

IF GUARDIA N, S TA TE RE LATIONS HIP: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

THIS DOCUMENT CONTAINS CONFIDENTIAL INFORMATION THAT IS LEGALLY PRIVILEGED. THIS INFORMATION IS INTENDED ONLY FOR USE OF THE FACILITY LISTED ABOVE. THE
AUTHORIZED RECIPIENT OF THIS INFORMATION IS PROHIBITED FROM DISCLOSING THIS INFORMATION TO ANY OTHER PARTY UNLESS REQUIRED BY LAW. IF YOU ARE NOT THE INTENDED
RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISCLOSURE, COPYING, DISTRIBUTION, OR ACTION TAKEN IN RELIANCE ON THE CONTENTS OF THIS DOCUMENT IS STRICTLY
PROHIBI I H./. IF YOU RECEIVE THIS FAX IN ERROR, PLEASE NOTIFY SENDER IMMEDIATELY AND ARRANGE OR ITS RETURN OR DESTRUCTION OF THIS DOCUMENT.
 REVIVE HEALTH CENTER
4734 W. Waco Drive, Waco Texas 76710
254-230-8281

MEDICAL HISTORY QUESTIONNAIRE

Date Name Date of Birth HT

Current Medical Complaints Current Medications

1. 1.
- 2.
2

3. 3.
4.
4.

Medication Allergies/Sensitivities
5.

1.1__________________________________ Drugs Frequently or Presently Used:

2. ______________________________ Sleeping Pills Thyroid

Tranquilizers _Heart Pill
Anti-Depressant Digitalis
3. _______________________________ Diet Pills ___ Water Pill
Estrogen Hormone Blood Pressure Pill
Hospitalizations (please list on back if more) Birth Control Pill Antacids
Laxative Vitamin D
_Decongestant Vitamins
1. Diabetic Pill Antibiotics
Asthma Pill Insulin
2. Nitroglycerin *Recreational Drugs"
Iron Other
Medical Problems Previously Treated Surgeries/Accidents

1-\\JIR__________________
2.
3. 3
.
Date of Last Mammogram_________________________________ LivingWill Yes
Date of Last Colonoscopy _______________________
Date of Last Glaucoma Check

Social History:
Occupation ____________________ Marital Statu M W D

Smoking: Alcohol Coffee

Packs Per Day ._ _ _ _ _ _ _ _ Drinks Per Day
Cups Per Day
Years Smoked ________
Years Stopped ________________ Aspirin
Pipe ______ Cigar ______Chew _____ Tabs Per Day
 Vaccinationsllnjections
OTetanus __________________ Date OH antis B Date
DPneumonia __________________ Date u - 1Date
DMeasies __________________ Date Shingles _________________ Date
OHormone _________________ Date DOther _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date
ElHepatitis A __________________ Date

FAMILY HISTORY
Please provide your FAMILY's health history below by checking the boxes for mother and father, and specifying
other relatives (grandfather, for example) on the line provided. Family includes mother, father, brothers, sisters
and grandparents.

Mother Father, Other Relative (Which one)

Er -I_________________________ High Blood Pressure
E H e a r t D i s e a s e

Fl B r e a s t C a n c e r

1:1 C o l o n C a n c e r
___________________ Other Cancer
-, Mental Illness

__________________ Stroke

_____ Diabetes

HAVE YOU ANY OF THE FOLLOWING IN THE LAST THREE MONTH

No Yes, Please Explain
Chills
Sweats
Weight Loss/Gain
Fatigue
Weakness
Skin Rash, Lumps, Nodules
Tumor or swelling
Headaches
- -- - I
Eye Troubles
Ear Troubles
-Pain
- -
-Hearing Loss
-Ringing -
1mbalance/Dizziness
 No Yes, Plea se exp la in
Nose Troubles-sinusitis
,-Bleeding __
'-Stuffiness
-Drainage
-riuy rover
Throat troubles
-Hoarseness
-Pain

Lymph node swelling

Lung troubles
:-Shortness of breath rest

-Shortness of breath @ exercise 42_

-S leep s s itt in g u p d u e to S . O. B -
Awakens at night due S.O.B
. W h e e z i n g
'-Asthma
'-Cough
-Pneumonia
Bronchitis 1

Heart troubles
-Chest pain 1/
. .
-Skipping heart beats
Irregular heart rhythm 7;
-Heart murmur
_
-Heart failure
-Black out spells
-Hypertension

:-Low blood pressure ti

-Ankle swelling
.
GI Problems
_
-Loss of Appetite
eating up quickly with ea
with swallowing
_________________________ Food catching with swallowing
_________________________ Pain with hot/cold/fuzzy drinks
-Abdominal pain -Nausea/Vomitting
-Vomitting blood
HAVE YOU EVER EXPERIENCE ANY OF THE FOLLOWING:

No Yes, Please explain

Heartbum/ind igestion
-

Nenous stomach V- -
History of stomach ulcers
. .
Diarrhea
Constipation
History of colitis

 Randy Bryson, FNP
REVIVE HEALTH CENT
4734 W. Waco Drive
Waco, Texas
(254) 230-8281 Phone

ACKNOWLEDGEMENT OF PRIVACY RIGHTS

Patient Name:

Protected health information (PHI) will only be released from our practice with a properly executed
authorization from the patient or his/her personal representative, except for treatment, payment, or
health care operations (11-10) and as otherwise required by law. Examples of some instances in which
we are required to disclose your PIE include:
Public health activities; information regarding victims of abuse, neglect, or domestic violence;
health oversight activities; judicial and administrative proceedings; law enforcement purposes;
organ donations purposes; research purposes under certain circumstances; national security and
intelligence; correctional institutions; and
Worker's Compensation.

REVIVE HEALTH CENTER will only use or disclose PHI, except as noted above,
consistent with the terms of the authorization.

A patient may revoke his authorization to use or disclose PHI at any time but actions taken prior to
the revocation are excluded. If authorization is a condition of obtaining insurance coverage, and
the authorization is revoked, the insurer may contest a claim under the policy.

Authorizations must be properly executed by the patient or his personal representative. It should
include, the date signed, specific PHI to be released or used, to whom this use or release relates, and
an expiration date for the authorization.

My signature confirms that I have been informed that I have rights to privacy regarding my protected
health information, and I have been given the opportunity to review this office's Notice of Privacy
Practices as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA),

Patient Signature Date

Relationship to Patient (if applicable)

Dependent family members are also covered by this acknowledgement.

D ate
 Randy Bryson, FNP
REVIVE HEA LTH CE NTER
4734 W. Waco Drive
Waco, Texas
(254) 230-8281 Phone

Authorization For Disclosure of Protected Health Information

List the phone numbers where we may leave detailed messages specifically for you:
None
Home Mobile

Work Other

With my signature below I acknowledge and understand that this information will be kept in my medical record and the above
parameters will be abided by until revoked by me in writing. It is my responsibility to notify my healthcare provider should I change one
or more of the telephone numbers listed above.

List the designated parties with whom we may leave messages (not doctors): _This
authorization will expire one year from the date signed by the patient or patient's representative _ This
authorization is effective for the lifetime of the patient unless revoked in writing.

NAME RE LA TIONS HIP NAME RELATIONSHIP

NAME RELATIONSHIP NAME RELATIONSHIP

NAME RELATIONSHIP NAME RELATIONSHIP

This authorization grants permission to the Designated Parties above to exchange my private medical information with Revive H ealth
Center and Randy Bryson FNP / David Martincheck MD and any authorized representative thereof, without restriction in terms of
content, purpose or means of transmission. This authorization includes, but is not limited to: making or confirming appointme nts;
accession any and all x-ray, laboratory or test information; access to telephone communication and treatment plans; direct di scussion of
my health with my doctor or other provider, any have access to my financial information as it relates to my health.

I understand that providing this authorization is voluntary

I understand that my treatment cannot be conditioned on whether I sign this authorization
I understand that it is my responsibility to notify my healthcare provider should I amend one or more of the Designated Parti es
listed above.
I understand that once this information is disclosed to the Designated Parties, the released information may no longer be
protected by federal privacy regulations.
I understand that I may revoke this authorization at any time by notifying Revive Health Center in writing. If I do
revoke the authorization, it will not have any effect on any actions taken by Revive Health Center prior to receipt of the
revocation.

P int Sig a ure

Date
 PAIN DRAWING

Please indicate what symptoms you're having NOW by writing the appropriate letter(s) on the affected body
part(s). Feel free to make up your own letter(s) if those below don't adequately describe your symptoms.

r A = Aching
B = Burning
C = Clicking, popping, snapping
G = Grating, grinding
N = Numbness
P = Pins-and-needles
S = Sharp, stabbing
T = Throbbing
W = Weakness

= ___________
=

RIGHT LEFT LEFT RIGHT

0
 Patient Name: - 4,4 L./VT U t./l IA LU Page 1 of 2

Chief Complaint: -0- - 4-

_______________ f Date: 4110(11--
Time:
1-1irorx of Pre ent Illness: ____________________ 1.)

L 4-Le_
647{-1- /74 k/ "7"-AiCe.'ine
r)L3rt w j24.4.
artfliC jf,e4) "j r fipr t
ZYZ-e______ _ A l l cut ./--c-aco,- I 5-
w r a i z e - 5 A a ,r6 ; 6jc_ -/e) r eao

Review of Systems: 11 Unobtainable due

to _____________________________
General: fatigue f 1 1,1 / CV: chest pain yes no
GU: dysuria )7.t-J,
weight loss frequency
fever f 1 1)// edema [I V hematuria E l Ir Endo: polyuria
chills [ i br PND E 1 1,1" discharge E1E polydypsia
night sweats 11 L.1/ orthopnea H fer menstrual problems f1f polyphagia
Eyes: visual change I1[ palpitations fy Muso-skel: arthralgia [ [ heat/cold intolerance
pain H fi r, claudication arthritis H 1_1 Derni: rash 1I EA
redness f 1 14 RP: cough 1/1 joint swelling pruritis
ENT: headaches f 3 II/ SOB f m a-.ias H A Neuro: weakness
hoarseness 11 L' wheezing f EY .44 f t_y seizures
sore throat f I 1-,3 7
hypersomnolence M
f I f,11
GI: abdominal pain 11 PI'
YrniA bleeding Ey' [i paresthesias
epistaxis f 1 [a// stool c:hanges brusing [ 1 tremor
sinus symptoms H fILY41, dotting scope
H 14nausee/vomiting transfusions
hearing loss H 4 diarrhea f I 1" Psych: anxiety [ I
tinnitus H U 'heartburn H 141 lymph node swelling [ 4 depressi on
blood in stool H 14" II [-I hallucinations
[ I Er] All/Imm: hayfever
[I 1./T bee sting allergy
Other ROS: Vi(etner ROS reviewed and were NORMAL

Past Medical History: -5

e-e- pro- Allergies: [i] NKDA Other; /1(4 0 y--tc-titt
Medications: See

Past Surgical History:

Family History: ___________________________

Social History: _____________________________

r
-

Cigs []No [ - Pack-yrs:

DOH [ No [ Yed 0 Amount0e)
Mid Yes Type: L.:
 REVIVE HEALTH CENTER
4734 W. Waco Drive, Waco Texas 76710
254-230-8281

I Date of service: Waiver? IJ

. ,
( i ..,_,I 1 ... I.> flitia3Criber
Address:
.,.. - ,e." Group t
C on:
Previous balance:
Today's charges:
Phone: Account tt. Today's payment checilt
DOB: Age: Sec Ptlyskian name: LBalance due.

immunizations & Injections Units

11111=M111111.11111411 9 9 2 1 1
Officevisit En irlecUon, joint, small 20600
El Problem focused 99201 99212 Injection, joint, intermediate 20605
Ell -nded - focused 99202 99213 Injection, joint, major 20610
MI Detailed Migl 99214 Injection, thertproptddiag 90772
11.1Coopreheasive Qumlam
imo Injection, trigger point 20552

MM..:1nificant,

=. ..:21= service ,
-r t
99205
-25
NEB
Supplies

Radiology= ,

11,14444444,---=,:tJb HiScelfaneoiit services -

4.4t/e"4' i --

Spine/Torso
M54.14 Radiculopathy, thoracic region M54.15
Diagnoses Racaculopathy, thcracolumtar region M54.16
044-15 6. Rarficulopathy. lumbar region M54.17
2 AA t , Az_, Radiculoptithy, lurnbosacral region
3 if/tVi r i

HEAD and NECK

4
Next office visit
Recheck Prey PRN D W MY
G44.309 Post-traumatic headache, unspecified, not intractable
G44.329 Chronic post traumatic Headache
S06.0X0A. concussion without toss of consciousness, initial encounter
Instructions:
M54.81 Occipital Neuralgia

Extremities
M79.601 Pain in right arm
Ogefral,- left arm
M 79.602 P ain s
M79.603 Pain in arm, unspecified
right leg M79.605 Pain in left leg
'nstructions: Ey-abate and teat consider modaties to .. I M79.604 Pain in
M79.606 Pain in
lag, unspecified
: dress joint and soft tissue inflammation and pain. Joint unspeciTied Irnb
I ." I 1reyenal and scar tissue formation. Consider relief M79.609 Pain in
arm
uligef
.' pain and restoration of function. Daly attention and M79.621 Pain in left uPPer aim
rcgressive reduction for 4-6 weeks at your discretion. M79.622 Pain in unspecified upper arm
M79.629 Pain in right forearm
PhySiCiin512 nature ,. M79.631 Pain in left forearm
. 71 i M79.632 Pain in unspecified forearm
- r M7 9 . 6 3 9 Pain in tight hand
X -- I _____________________________________________________________________
M79.641 Pain in left hand
M79.642 Pain in unspecified hand
M79.643 Pain in rfgl finger(s)
Cervical M79.644 Pain to left fingef(s)
M48.31 traumatic spcodylopattry occipital afianto axial M79.645 Pain in unspecified (s) M79.651 Pain in right thigh
M48.32 Traumat ic spordylop athy cerv ical reg ion M79.646 Pain in left thigh M79.659 Pain in urrspecified thigh
M54.12 Racriculopathy Cervical Region M79.652 Pain in right lower leg M79.662 Pain in left lower leg
M79.661 Pain in unspecified lower leg
Thoracic M79.669 Pain it right foot left
M99.02 Somatic Dysfunction thoracic M79.671 Pain n foot unspecified
M48.84 Traumatic Spcodylopathy Thoracic Region M79.672 Pain in foot
M54.15 Rarkulopathy Thoracic Region M79.673 Pain in right toe (s)
M79.674 Pain in l e ft toes)
M79.675 Pain in unspecified toe(s)
Traumatic spondylopathy Lumbar M7 9 . 6 7 6 Pain in
M54.41 Lumbago right side
M54.42 Lumbago left side Chronic Pain
M99.04 Somatic dysfunction sacral region G9.21 Chronic Pain due to trauma
M99.05 Somatic dysfunction Pelvic region
M 1 sciatic right
M54.3 sciatica left

M 6 2 . 0 M u s c l e sp a s m o f b a c k