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7 Patient History Form Date of first appointment: / / Time of appointment: Birthplace: mm dd yyyy Name: Birthdate: / / LAST FIRST MIDDLE MAIDEN mm dd yyyy Address: STREET APT# Age: Sex: F M Telephone: H CITY STATE ZIP W C Referred by: (check one) Self Family Friend Physician Other Health Professional Name of Person Making Referral: Name of Primary Care Physician: PRESENT PROBLEM DIAGNOSIS: Problem onset Present symptoms Severity 1-10 Location Pain quality Aggravated by Relieved by Please shade all the locations of your pain over the past week on the body figures Drug allergies: No Yes To what? Type of reaction: 1
8 PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements) Name of Drug Dose Number of pills and how often? How long have you taken this medication? Please check: Helped? A Lot Some Not at all PAST MEDICAL HISTORY Do you now or ever had: (check if yes ) Cancer type Heart attack Goiter Angina Depression/Anxiety Heart Failure Nervous Breakdown Diabetes High Blood Pressure Stomach Ulcers Stroke Liver Problems Asthma Kidney Problems Leukemia Osteoarthritis Rheumatic Fever Gout Bleeding Tendency Childhood Arthritis Alcoholism Psoriatic Arthritis Epilepsy Osteoporosis SURGERIES: Total knee replacement Total hip replacement Back Surgery Hysterectomy Prostate Other Thyroid Problems Lung Problems type Anemia Cholesterol HIV/AIDS Glaucoma Hepatitis Ankylosing Spondylitis Scleroderma Lupus or SLE Rheumatoid Arthritis Arthritis (unknown type) Colitis Psoriasis Tuberculosis Other significant illnesses (please list) Family History: IF LIVING IF DECEASED Father Mother Age Health Age at death Cause Number of siblings Number living Number deceased Sisters Brothers Number of children Number living Number deceased List ages of each Daughters Sons Adopted 2
9 At any time has a blood relative had any of the following? (give relationship) Arthritis (unknown type) Osteoarthritis Gout Childhood arthritis Lupus or SLE Rheumatoid Arthritis Ankylosing Spondylitis Osteoporosis Psoriatic Arthritis Scleroderma Rheumatic Fever Other arthritis conditions: Relative Relationship Cancer Leukemia Stroke Colitis Heart Disease High Blood Pressure Bleeding Tendency Alcoholism Asthma Epilepsy Diabetes Goiter Relative Relationship SOCIAL HISTORY Primary language spoken: Hand Dominance Right Left Education (circle highest level attended) Grade School College Graduate School Occupation: Number of hours worked/average per week Employer: Retired Date Military Service: yes No Current status: MARITAL STATUS: Never Married Married Divorced Separated Widowed Spouse/Significant Other: Alive/Age Deceased/Age Major Illnesses Do you smoke? Yes No Past How long ago? Packs a day Number of years Do you drink alcohol? Yes No Number per week Has anyone ever told you to cut down on your drinking? Do you drink caffeinated beverages? Yes No Type of Beverage Cups/Glasses per day? Do you use drugs for reasons that are not medical? Yes No If yes, please list: Activity Level: Sedentary Moderate Vigorous Type of Exercise: Aerobic Golf Jogging Skiing Swimming Walking Yoga Other Exercise Frequency: Times/week House Pets: Yes No Type: Recent Travel: Out of State International DIAGNOSTIC TESTS MRI Scan CT Scan Biopsy 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 / / 3
10 REVIEW OF SYSTEMS As you review the following list, please check any of those problems which have significantly affected you. Constitutional Fatigue Fever Malaise Night sweats Recent weight gain Recent weight loss amount amount HEENT Eye dryness Eye Pain Redness of eyes Visual Changes Ears-Nose-Mouth-Throat Loss of hearing Loss of smell Dry Mouth Nose Bleeds Sores in mouth Difficulty swallowing Hoarseness RESPIRATORY Shortness of breath Cough Coughing up blood Wheezing (asthma) CARDIOVASCULAR Chest Pain Difficulty in breathing at night Swollen legs or feet Irregular heart beat VASCULAR Cool extremity Ulcer Raynaud s Thrombosis phlebitis GASTROINTESTINAL Abdominal pain Jaundice Diarrhea Heartburn Vomiting Increasing constipation Nausea Blood in stools Changes in stools GENITOURINARY Difficulty urinating Blood in urine Increased urinary frequency Urinary incontinence REPRODUCTIVE Female Vaginal Discharge Breast Discharge Vaginal Dryness Sexual Dysfunctions Irregular Menses Male Penile Discharge Sexual Dysfunctions ENDOCRINE Excessive thirst (Polydipsia) Abnormal sleep Goiter Tremors Hair Changes NEUROLOGICAL SYSTEM Gait disturbance Headaches Dizziness Memory Loss Vertigo Extremity Numbness Seizures PSYCHIATRIC Depression Anxiety Insomnia INTERGUMENTARY SKIN Sun sensitive (sun allergy) Hair loss Rash Hives Skin Thickening MUSCULOSKELETAL Back pain Joint pain Morning stiffness Joint swelling Muscle tenderness Muscle Weakness Neck pain Lasting how long? Minutes Hours HEMATOLOGIC/LYMPHATIC Eye bruising Easy Bleeding Swollen Glands Anemia ALLERGIC/IMMUNOLOGIC Asthma Seasonal Allergies Food allergies Environmental allergies 4
11 PAST MEDICATIONS Name of Drug Non-Steroidal/Anti-Inflammatory Drugs (NSAIDs) Ansaid (flurbiprofen) Length of time Please check: Helped? A Lot Some Not at all Reactions Arthrotec (diclofenac + misoprostil) Aspirin (including coated aspirin) Celebrex (celecoxib) Clinoril (sulindac) Daypro (oxaprozin) Disalcid (salsalate) Dolobid (diflunisal) Feldene (piroxicam) Non-Steroidal/Anti-Inflammatory Drugs (NSAIDs) Length of time Indocin (indomethacin) Lodine (etodolac) Meclomen (meclofenamate) Motrin/Rufen (ibuprofen) Nalfon (fenoprofen) Naprosyn (naproxen) Oruvail (ketoprofen) Tolectin (tolmetin) Trilisate (choline magnesium trisalicylate) Vioxx (rofecoxib) Voltaren (diclofenac) Please check: Helped? A Lot Some Not at all Reactions Pain Relievers Acetaminophen (Tylenol) Length of time Please check: Helped? A Lot Some Not at all Reactions Oxycodone, Percocet, Oxycontin Propoxyphene (Darvon/Darvocet) Please check: Helped? Disease Modifying Antirheumatic Drugs (DMARDS) Length of time A Lot Some Not at all Reactions Gold Salts/pills (Myochrysine or Solganol) Hydroxychloroquine (Plaquinil) Penicillamine (Cuprimine or Depen) Methotrexate (Rheumatrex) Azathioprine (Imuran) 5
12 Sulfasalazine (Azulfidine) Cyclophosphamide (Cytoxan) Cyclosporine A (Sandimmune, Neoral or Gengraf) Etanercept (Enbrel) Infliximab (Remicade) Adalimumab (Humira) Rituximab (Rituxan) Abatacept (Orencia) Leflunimde (Arava) Osteoporosis Medications Length of time Estrogen (Premarin, etc.) Alendronate (Fosamax) Etidronate (Didronel) Raloxifene (Evista) Flouride Calcitronin injection or nasal (Miacalcin, Calcimar) Residronate (Actonel) Boniva Please check: Helped? A Lot Some Not at all Reactions Gout Medications Length of time Please check: Helped? A Lot Some Not at all Probenecid (Benemid) Reactions Colchicine Allopurinol (Zyloprim/Lopurin) Other Medications Length of time Tamoxifen (Nolvadex) Tiludronate (Skelid) Cortisone/Prednisone Hyalgan/Synvisc injections Herbal or Nutritional Supplements Please check: Helped? A Lot Some Not at all Reactions Please list supplements: Have you participated in any clinical trials for new medications? Yes No If yes, list: 6
13 MDHAQ NAME: Address: Primary Care Physician: DATE: Preferred Contact Method: This questionnaire includes information not available from blood tests, X-rays, or any source other than you. Please try to answer each question. There are no right or wrong answers. Please answer exactly as you think or feel. Thank you. Please check ( ) the ONE best answer for your abilities at this time: OVER THE PAST WEEK, were you able to: Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do Dress yourself, including tying shoelaces and doing buttons? Get in and out of bed? Lift a full cup or glass to your mouth? Walk outdoors on flat ground? Wash and dry your entire body? Bend down to pick up clothing from the floor? Turn regular faucets on and off? Get in and out of a car, bus, train, or airplane? Walk two miles? Participate in sports and games as you would like? Get a good night s sleep? Deal with feelings of anxiety or being nervous? Deal with feelings of depression or feeling blue? Pain Scale How much pain have you had because of your condition OVER THE PAST WEEK? Please indicate below how severe your pain has been: NO PAIN PAIN AS BAD AS IT COULD BE 3. Patient Status Considering all the ways in which illness and health conditions may affect you at this time, please indicate below how you are doing: VERY WELL VERY POORLY 4. Clinical Trials Are you interested in learning about participation in our clinical trials program? Yes No
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Name: Birthdate: / / LAST FIRST MIDDLE mm dd yyyy. Address: STREET CITY APT # STATE ZIP. Name of Person Making Referral:
Patient History Form Date of first appointment: / / mm dd yyyy Time of appointment: Birthplace: Name: Birthdate: / / LAST FIRST MIDDLE mm dd yyyy Age: Sex: F M Telephone: (H) (C) (W) Address: STREET CITY
Patient History Form
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Patient History Form
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HAQ-II(Health Assessment Questionnaire-II)
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Date of first appointment: / / Name: Birthdate: / / LAST FIRST MIDDLE INITIAL MAIDEN MONTH DAY YEAR Address: Age: Sex: F M Telephone: Home ( )
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NEW PATIENT INFORMATION
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Premier Internal Medicine of Alpharetta, PC
Patient Information Date / / First Name Middle Initial Last Name Date of Birth / / Social Security # Gender Male Female Marital Status Single Married Separated Divorced Widowed Address Apt # City State
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
LAKES INTERNAL MEDICINE
LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
medical questionnaire Date: Day Month Year
medical questionnaire Date: Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment
Rheumatology Associates of North Jersey New Data Sheet
Personal History Rheumatology Associates of North Jersey New Data Sheet To our new patients: Welcome to our practice. SS: - - Date: Last Name: First Name Date of Birth / / Age Address City State Zip Code
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
FIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA
Department of Radiation Oncology FIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA 90095 310-825-9775 1. Complete ALL important Patient
Allina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History
NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C.
NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C. Past Medical History AIDS/HIV disease Anemia Asthma Bronchitis Cancer Date of last Chest X-ray Diabetes Mellitus, Type I Diabetes Mellitus,
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL NAME: BIRTH DATE: AGE: SEX: M F OCCUPATION: RACE: WHO REFERRED YOU TO OUR OFFICE? _ WHAT IS YOUR MAIN COMPLAINT? HOW LONG HAS THIS BEEN A PROBLEM? IS