Fillable DIRECTIONS 1320 Stony Brook Road Building F, Suite#200 (Academic medical center at State University of New York at Stony Brook)

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DIRECTIONS 1320 Stony Brook Road Building F, Suite#200 (Academic medical center at State University of New York at Stony Brook)

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BROWSE ACADEMIC MEDICAL CENTER AT STATE UNIVERSITY OF NEW YORK AT STONY BROOK FORMS

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DIRECTIONS
1320 Stony Brook Road
Building F, Suite#200
Stony Brook, NY 11790
Directions to our office can be obtained by calling our main number @ 631-444-4200 and pressing
option 5
*Please note that there is another entrance on 347 Nesconset Highway (it is the 1
st
right turn after the
traffic light at 347 Nesconset Highway & Stony Brook Rd.) traveling West. If traveling East, one would
need to make a legal U-turn at this traffic light to access. Once you enter, make a right after the yield
sign or go straight and loop around to access parking near Building F*
• From the LIE (Long Island Expressway) take exit 62 North to Route 97/Nicolls
Road. Stay on Nicolls Road for approximately 8 miles and turn left on Route
347/Nesconset Highway heading west. At the 2
nd
light turn right on Stony Brook Rd. and
turn left into the shopping center either after Duane Reade or after Ralph’s Italian Ices
• From the NS (Northern State Parkway North) take to the end & follow signs for
Route 347 (Nesconset Highway) heading east for approximately 9 miles. Turn left on
Stony Brook Road and turn left into the shopping center either after Duane Reade or after
Ralph’s Italian Ices
• From Route 347 (Nesconset Highway) traveling West turn right onto Stony Brook
Road and turn left into the shopping center either after Duane Reade or after Ralph’s
Italian Ices
• From Route 347 (Nesconset Highway) traveling East turn left onto Stony Brook Road
and turn left into the shopping center either after Duane Reade or after Ralph’s Italian
Ices
• From 25A traveling East turn right onto Stony Brook Road just before 347 (Nesconset
Highway) and turn right into the shopping center either after Duane Reade or after
Ralph’s Italian Ices
• From 25A traveling West turn left onto Stony Brook Road just before 347 (Nesconset
Highway) and turn right into the shopping center either after Duane Reade or after
Ralph’s Italian Ices
Name: _____________________________ DOB: _____________
STONY BROOK DERMATOLOGY ASSOCIATES
REASON FOR VI
SIT: __________________________________________________________
WEIGHT_________ HEIGHT_________
ALLERGIES______________________________________________________________________
DO YOU FEEL WELL TODAY? YES NO
o If no what are your symptoms
ARE YOU HAVING ANY PAIN? YES NO
o If yes, please tell us your pain level from 0-10 (0=none, 10 = worst)
o What is your pain tolerance (threshold)?
NO
WHAT IS YOUR PRIMARY LANGUAGE?_____________________
BARRIERS TO LEARNING: i.e.: impaired vision, hearing, reading or speaking YES
o If yes, pl
ease explain
PATIENT/PARENT LEARNING PREFERENCES (Please check at least one)
DEMONSTRATION EXPLANATION
PRINTED MATERIALS VIDEO WEB BASED
DO YOU PR
EFER SOMEONE PRESENT DURING TEACHING? YES NO WHO __________
DO YOU HAVE CULTURAL/RELIGIOUS PRACTICES THAT AFFECT PROVISION OF YOUR
HEALTHCARE? YES NO If yes please explain __________________________
DO YOU HAVE TROUBLE WALKING OR STANDING? YES NO
HAVE YOU FALLEN IN THE PAST 12 MONTHS YES NO
DO YOU HAVE A FEAR OF FALLING YES NO
WHEN WAS YOUR LAST INFLUENZA VACCINE?
NAME
DOSE
HOW MANY TIMES A DAY
TAKEN
Please list your MEDICATIONS or provide copy- If you need additional space please add to end of sheet.
(If none, please indicate "none")
Name: _____________________________ DOB: _____________
DO YOU USE TOBACCO YES NO
HAVE YOU EVER USED TOBACCO YES NO
DO YOU USE ALCOHOL YES NO
o How much
DO YOU FEEL SAFE AT HOME YES NO
DO YOU HAVE A FAMILY HISTORY OF:
NO
___ MELANOMA Who/Type? _____________
___ OTHER TYPES OF SKIN CANCER Who/Type? _____________
___ ANY CANCERS Who/Type? _____________
___ Other skin diseases & Who/Type?
HAVE YOU EVER BEEN DIAGNOSED WITH MELANOMA? YES NO
HAVE YOU EVER BEEN DIAGNOSED WITH ANY OTHER TYPE OF SKIN CANCER? YES
LIST ALL MEDICAL PROBLEMS (If none, please indicate "none")
o Heart valve problems: Yes No
o Artificial joints: Yes No
o Hepatitis: Yes No
o Pacemaker/Defibrillator: Yes No
o Do you need antibiotics before procedures? Yes No
LIST ANY PROCEDURES (If none, please indicate "none")
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
E-Prescribing Consent Form
Patient’s Name __________________________________ Date of Birth: ____________________
Stony Brook Dermatology Associates, UFPC is in the process of implementing e-Prescribe (electronic prescribing) in
our ongoing efforts to maximize patient safety.
Total Quality in patient care is just one of our ongoing commitments…
Patient benefits:
• Less confusion over handwritten prescriptions or unclear phone calls
• Reduced possibility of medical errors
• Less chance of adverse drug reactions
• Fewer trips to drop off at the pharmacy
• A safer, faster & easier way to get your prescription filled
_______________________________________
_______________________________________
Please list any DRUG allergies:
___________________________________
____________________________________
____________________________________
_______________________________________
Please provide our office with your pharmacy name (s), address & phone number so that we may enter this data into
your medical record.
Patient Consent:
I agree that Stony Brook Dermatology Associates, UFPC may request and use my prescription medication history
from other healthcare providers or third party pharmacy benefit payers for treatment purposes. This consent form
will be updated on an annual basis.
_____________________________________
Patient Signature Date
Pharmacy Name (1
st
Choice):
_____________________________________
Street Name, Town OR ZIP CODE:
_____________________________________
Ph#: ________-_________-__________ (if known)
Fax#: ________-_________-__________
Pharmacy Name (2
nd
Choice):
_____________________________________
Street Name, Town OR ZIP CODE:
_____________________________________
Ph#: ________-_________-__________ (if known)
Fax#: ________-_________-__________
Name: _____________________________ DOB: _____________
COMMUNICATION CONSENT
STONY BROOK DERMATOLOGY
1320 Stony Brook Road
Building F, Suite #200
Stony Brook, NY 11790
It is the policy of Stony Brook Dermatology not to release confidential information other
than face to face without authorization to do so by alternative methods (Voice
Mail/Answering Machine/Telephone). Any information that will be provided will be
released only to the authorized person (s) listed below.
I authorize Stony Brook Dermatology, and/ or their staff to leave medical information
pertaining to my care by the following methods and will assume responsibility to notify
them whenever this information changes (please fill out all contact information).
Home Telephone: _______-_______-_______ YES NO
Answering Machine: YES NO
Work Telephone: _______-_______-_______ YES NO
Cell/ Voice Mail: _______-_______-_______ YES NO
E-mail: _____________________ _________ YES NO
Regular Mail: YES NO
If you would like to have information released to someone other than yourself, please
complete the following list of authorized people:
Spouse: ________________________________ Tel: _______-_______-_______
Adult Child: _________________________________ Tel: _______-_______-_______
Other (please indicate relation): _____________________Tel: _______-_______-_______
Preferred Tel: _______-_______-_______
Patient Signature: _______________________________ Date: _____________
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DIRECTIONS 1320 Stony Brook Road Building F, Suite200 (Academic medical center at State University of New York at Stony Brook)

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Completed 27 August 2020

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