1 I *********IF YOU ARE NOT ON ALLERGY SHOTS PLEASE SKIP THIS SECTION AND MOVE TO PAGE 2********* NAME: AGE: ---- ID (For Office Use Only):
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- Corey Clarke
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1 NAME: AGE: ---- Date of Appointment:. ID (For Office Use Only): RETURN VISIT Date of Visit: Main Reason for visit: Reevaluation Family Doctor: Symptoms worse _ New problem _ Yearly follow up _ Follow up/office Visit Main Concern(s): _ Allergy eye-ear-nose & throat problems _Insect sting allergy _ Recurring infections _ Medication allergy _ Food allergies _ Skin problems/eczema _ Asthma/Breathing problems Other: *********IF YOU ARE NOT ON ALLERGY SHOTS PLEASE SKIP THIS SECTION AND MOVE TO PAGE 2********* Are you currently on allergy shots: Yes No Allergy shots started: Are symptoms increased by the time your next shot is due: Yes No Dose: : : :1000 How often do you take _ Twice weekly Shots: _ Weekly _ Every 2 weeks _ Every 3 weeks _ Every 4 weeks _ Every 6 weeks Other: Where do you receive allergy shots: Little Rock Pine Bluff _ Bryant North Little Rock _ Primay Care Physician Any shot reactions since last visit: Yes No Have symptoms improved on shots: Yes No Unsure How much have symptoms improved since starting allergy shots: 25% 50% 75% 100% 1 I
2 Have you had any of the following since last visit: New medication allergies: Received Pneumonia vaccine: Yes No I don't know Month/Year Flu shot in past year: Yes No I don't know Month/Year New medical problems: New food allergies: New surgeries: Other: Social History Smoking status: _ Current every day smoker _ Current some day smoker Former smoker Never smoker Unknown if ever smoked Smoker - current status unknown Smoking type: _ Cigar _ Cigarettes _ Pipes Other: Smoking duration: _ N/A _1-5 years _ 6-10 years _11-20 years _ Over 20 years Maximum packs per day: Y2 1 1 Y2 2 or more Second hand smoke exposure: No Inside Outside Medication Use Summary Using allergy nasal spray: _ Occasionally _ Regularly No _N/A Using oral allergy meds: _ Occasionally _ Regularly No _N/A Using preventative inhaled asthma meds: _ Occasionally _ Regularly No _N/A Using preventative oral asthma meds: _ Occasionally _ Regularly No _N/A Using asthma rescue inhaler: _ Occasionally _ Regularly No _N/A Using eczema creams/ointments: _ Occasionally _ Regularly No _N/A Preventative/Prophylactic antibiotics: Yes No How many times have you taken antibiotics in the past 12 months: I Medication Name (pills, inhalers, sprays, creams, shots) Strength/Dose How Many How Many Times a Day
3 Allergy Symptoms Since Last Visit Active problems or symptoms: Yes _ No known problem IF NO KNOWN PROBLEMS SKIP BELOW Cough: Severe Moderate - Mild None Stuffiness: Severe Moderate _fv1 ild None Runny nose: Severe Moderate Mild None Post nasal drip: Severe Moderate Mild None Nasal itch: Severe Moderate Mild None Eye itch: Severe Moderate Mild None Tearing: Severe Moderate Mild None Sneezing: Severe Moderate Mild None Eczema: Severe - Moderate Mild None Hives: Severe Moderate Mild None Fever: Severe Moderate Mild None Clear nasal drainage: Severe Moderate Mild None Colored nasal drainage: Severe Moderate Mild None Sinus tenderness: Severe Moderate Mild None Headache: Severe Moderate Mild None Sore throat: Severe Moderate Mild None Earache: Severe Moderate Mild None Ear Drainage: Severe Moderate Mild None Fatigue: Severe Moderate Mild None Sputum: Severe Moderate Mild None Shortness of breath: Severe Moderate Mild None Wheezing: Severe Moderate Mild None Chest tightness: Severe Moderate Mild None Other: What are the worst seasons: Year round _Spring Summer Fall Winter
4 Long Term Course How would you rate your long term improvement: Worse A little better Much better _ Fully controlled N/A Eye, Ear, Nose & Throat Problems: Worse A little better Much better _ Fully controlled _N/A Asthma or Chest problems: Worse A little better Much better _ Fully controlled N/A Hives: Worse A little better Much better _ Fully controlled N/A Eczema: I Worse A little better Much better _ Fully controlled _N/A 1 Headaches: J, Worse A little better Much better _ Fully controlled N/A f! Sinus infections: Worse A little better Much better Fully controlled _N/A Allergy Symptoms Since The Last Visit Asthma Symptoms Since The Last Visit _ Problems only at peak times _ ER visit or hospitalization _ Often in yellow zone _ No problems or symptoms No ne'ed for rescue _ Flares with weather changes _ Very symptomatic all the time _ Exercise induced symptoms Flares with infections Well controlled with meds _ Generally doing well _ Symptomatic all the time _ Mild chronic problems _ Flares with allergy exposures _ Flares easily managed Infections That Have Occurred In Past 12 Months None Ear infection Tonsillitis Other infection Viral upper respiratory infection Sinusitis Pneumonia Skin infection Bronchitis Eczema Status Since The Last Visit _N/A _ Well controlled most of the time using creams/ointments only occasionally _ Well controlled most of the time using creams/ointments once or twice a day _ Partially controlled most of the time using creams/ointments once or twice a day _ Not controlled most of the time using creams/ointments once or twice a day Frequently a problem but creams/ointments are used occasionally or not at all Hives Status Since Last Visit _N/A Well controlled most of the time using medications only occasionally _ Well controlled most of the time using medications once or twice a day _ Partially controlled most of the time using medications once or twice a day _ Not controlled most of the time using medications once or twice a day _ Frequently a problem but medications are used only occasionally or not at all
5 Review of Systems (Current or within the last 12 months) General: Heart: Urinary Tract: Hematologic/ Lymphatic: Skin: [ I No Problems [ I Failure to thrive [ I Fevers [ I Chills [ I Sweats [ I Poor Appetite [ I Fatigue [ I Malaise [ I Weight loss [ I Chest pains [ I Congenital heart disease [ 1 Palpitations [ I Passing out [ I Murmur [ 1 Difficulty breathing on exertion [ 1 No problems [ I Pain on urination [ I Blood in the urine [ I Discharge [ I Urinary frequency [ I Bed wetting [ I Urinary infections [ I Urinary stones [ 1 No problem [ I Swollen glands [ I Easy bleeding or bruising [ 1 No problems [ 1 Rash [ 1 Suspicious lesions [ J Dryness [ J Itching [ I Boils [ 1 Hives! I Eczema Neurologic: Gastrointestinal: Metabolic: Psychiatric: [ I Paralysis [ I Weakness [ J Seizures [ I Passing out [ I Tremors [ 1 Dizziness [ 1 See HPI [ 1 Heartburn/GERD [ I Difficulty swallowing [ I Nausea [ I Vomiting [ I Abdominal pain [ 1 Constipation [ I Diarrhea [ I Change in bowel habits [ I Jaundice [ I Bloody stool [ I Cold intolerance [ 1 Heat intolerance [ I Excessive drinking [ I Excessive eating [ J Excessive urination [ 1 Unexplained weight change [ 1 See HPI [ J Hyperactivity [ 1 Behavior problems [ 1 Depression [ 1 Anxiety [ 1 See HPI Musculoskeletal:! J No problems [ 1 Back pain [ 1 Bone pain [ I Joint pain [ 1 Joint swelling [ 1 Muscle cramps [ 1 Muscle weakness [ I Stiffness [ I Arthritis
6 IF YOU ARE NOT HERE FOR ASTHMA RELATED SYMPTOMS PLEASE DO NOT COMPLETE Are you having (Asthma) breathing problems: Yes No How many years have you had symptoms: less than _over 30 Trend of asthma severity: Unchanged _Improving Worsening Steroid (Prelone, Pediapred, Prednisone) bursts in past year: _ over 10 Please answer yes or no to each of the following: ER visits for asthma in past year: Yes No How many in past year: Hospitalized for asthma in past year: Yes No How many in past year: Intensive care unit for asthma: Yes No Does patient have peak flow meter: Yes No Had a chest X-ray in the past year: Yes No If yes: Normal Abnormal Please indicate if you have had any of the following treatments. If you did have the treatment. please indicate if it was helpful or not helpful. Oral steroids (prednisone) or steroid shot in past: No _ Yes-Helpful Yes-Not Helpful Inhaled steroids (Pulmicort, Asmanex, Flovent, etc): No _ Yes-Helpful Yes-Not Helpful Combination inhalers (Advair, Symbicort, Dulera, etc): No _ Yes-Helpful _Yes-Not Helpful Singulair, Accolate, or Zyflo: No _ Yes-Helpful _ Yes-Not Helpful Home nebulizer machine: No _ Yes-Helpful _ Yes-Not Helpful Spacer device (attachment for inhaler): No _ Yes-Helpful _ Yes-Not Helpful Rapid-acting inhalers (Albuterol, Proventil, Proair, Ventolin, etc): No _ Yes-Helpful _ Yes-Not Helpful
7 IF YOU ARE NOT HERE FOR ASTHMA RELATED SYMPTOMS PLEASE DO NOT COMPLETE Are you being treated for Asthma: Yes No Patient is 12 years or older How much of a problem is your asthma when you run, exercise or play sports: It's a big problem -I can't do what 1 want to It's a problem and 1don't like it _It's a little problem but it's ok _It's not a problem During the past 4 weeks: Have you missed any work or school due to asthma: Yes No How much of the time did your asthma keep you from getting as much done at work, school, or at home: How often have you had shortness of breath: All of the time Most of the time Some of the time A little of the time None of the time More than once a day Once a day 3-6 times a week Once or twice a week Not at all How often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness, or pain) wake you up at night or earlier than usual in the morning: _ 4 or more nights a week _ 2 or 3 nights a week Once a week Once or twice Not at all How often have you used your rescue inhaler or nebulizer medication (such as albuterol): How would you rate your asthma control: _ 3 or more times per day lor 2 times per day _ 2 or 3 times per week Once a week or less Not at all Not controlled at all Poorly controlled Somewhat controlled Well controlled _ Completely controlled
8 IF YOU ARE NOT HERE FOR ASTHMA RELATED SYMPTOMS PLEASE DO NOT COMPLETE Patient is 4-11 years old (Please have child answer next 4 questions) How is your asthma today: _ Very Bad Bad Good _ Very good How much of a problem is your asthma when you run, exercise or play sports: It's a big problem -I can't do what I want to do It's a problem and 1 don't like it It's a little problem but it's OK It's not a problem Do you cough because of your asthma: No all of the time most of the time some of the time none of the time Do you wake up during the night becasue of your asthma: No all of the time most of the time some of the time none of the time During the past 4 weeks, on average, how many days (Answer by parent or care giver) Did your child have any daytime asthma symptoms: None _ 1-3 days/month _ 4-10 days/month _ days/month _ days/month _everyday Did your child wheeze during the day because of asthma: None 1-3 days/month 4-10 days/month _ days/month _ days/month _everyday Did your child wake up during the night because of asthma: None _1-3 days/month _ 4-10 days/month _ days/month _ days/month _every day
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Please fill out this form as completely as possible. This information will determine how we treat your pain problem.
Name Date of birth Age Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your
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,
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
ALLERGY & ASTHMA SPECIALISTS, P.C.
ALLERGY & ASTHMA SPECIALISTS, P.C. Leonard Silverstein, M.D. Ruth L.K. Gold, M.D. Health Questionnaire Jennifer A. Sherman, D.O. Niya Wanich, M.D Patient: D.O.B.: / / Age: Date: / / Height: Weight: Reason
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
Medical History Form
Dr. Vivek U. Rao, M.D. 500 Adams Ave., Suite 300 Odessa, TX 79761 Phone: 432.333.3300 Fax: 432.339.3300 Medical History Form Patient Name: DOB: A. CHIEF COMPLAINT: Briefly describe your (or your child
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY NAME: _ DATE: Please complete the following questionnaire as completely as possible. 1. MEDICAL HISTORY Please list all current and prior health problems,
Past Medical History. Chief Complaint: Appointment Date: Page 1
Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty
SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:
PATIENT INFORMATION (PLEASE PRINT) SOC SEC #: - - MRN#: Home Phone: Work Phone: Ext: Address: City: Cell Phone: Date of Birth: - - Age: yrs State: Zip Code: Employer: SEX: Male Female Work Address: City:
Medical Questionnaire
MEDICIS Health Testing Center Avenue de Tervueren 236 115 Bruxelles Tel : 2/762.5.44 Medical Questionnaire Name :. Maiden name : First name :. Sex :. Address :...... Phone (private) : Office :. Date of
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother
Silver Child Development Center New Patient Questionnaire Today s Date Mother s Name First Last Date of Birth Relation (circle) Biological Mother Stepmother Adoptive Mother Foster Mother Other Father s
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
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
Name: Date: 1. What is the principal reason for consulting us?
Name: Date: 1. What is the principal reason for consulting us? 2. Circle any of the following that you have had: Sneezing Runny nose Stuffy nose Shortness of breath Phlegm Headaches Watery eyes Swelling
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM
Name Date Address City State Zip Home Phone Cell Fax Email Emergency Contact Emergency Number Date of Birth Age Sex Height Weight Lbs Marital Status Occupation Who referred you to this office? Name of
INITIAL PATIENT FORM
Patient : INITIAL PATIENT FORM Reason for your visit: Visit Date: Left CIRCLE AREA(S) OF CONCERN: Right TOP/BOTTOM OUTSIDE INSIDE Type of pain: Sharp Burning Soreness Tightness Stabbing Numbness Aching
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
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
Wisconsin Integrative Pain Specialists
Patient Information Today s Date: Patient s Name: DOB: Age: Gender: Marital Status: M S D What would you like us to call you? Address: City, State, Zip: Home Phone: Cell Phone: Work Phone: Email: Preferred
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: