Allina Health United Lung and Sleep Clinic
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- Derrick Chandler
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1 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 Single [ ] Married [ ] Divorced [ ] Widowed [ ] Number of children Race/Ethnic Background: American Indian or Alaska Native [ ] Asian [ ] Black or African American [ ] Hispanic or Latino [ ] Native Hawaiian/Other Pacific Islander [ ] White [ ] Choose not to disclose/declined [ ] Unknown [ ] Country of Birth: United States [ ] Other Are you currently: Working [ ] Retired [ ] Unemployed [ ] Disabled [ ] Occupation(s) List most recent first (including former careers if you are retired or not working): 1) 2) 3) 4) Leisure activities: SR (09/13) 1
2 Please answer these questions with regard to your current health status. Trouble Breathing (hard to breathe, chest tightness, shortness of breath) How long have you been bothered by shortness of breath? How far can you walk on level ground at your own pace without stopping? ( for example: 20 feet, ½ block, 3 block, 1 mile, etc.) How many flights of stairs can you walk without stopping? Please circle: 0 ½ or more Yes No Do you have shortness of breath when you lie down in bed? [ ] [ ] Do you wake up in the middle of the night with shortness of breath? [ ] [ ] Do you wake up in the morning with shortness of breath? [ ] [ ] Do you have to walk slower than people of your age on level ground because of breathlessness? [ ] [ ] Do you wheeze or make noise when you breathe? [ ] [ ] What situations, places or activities make your shortness of breath worse? Dust or fumes [ ] Tobacco smoke [ ] Weather changes/humidity [ ] Wood smoke [ ] Perfumes [ ] Exercise [ ] Emotions [ ] Cold air [ ] Household cleaning solutions [ ] Places that cause you to have shortness of breath: Other things that will cause shortness of breath: Things that will make your breathing better: Cough Yes No Do you cough often? [ ] [ ] Do you cough some every day? [ ] [ ] If not every day, how often? How many years have you been coughing? Do you cough up phlegm (sputum) when you do cough? [ ] [ ] Every day or most days? [ ] [ ] Every week? [ ] [ ] 3 months out of the year? [ ] [ ] Other? [ ] [ ] SR (09/13) 2
3 Yes No Do you usually cough up some phlegm first thing [ ] [ ] in the morning? How many years have you been coughing up phlegm? Have you ever coughed up bloody phlegm? [ ] [ ] How much? Chest Pain Yes No Do you have chest pain? [ ] [ ] Only during activity? [ ] [ ] At rest during the day? [ ] [ ] At night? [ ] [ ] Other? If you have chest pain, how often does it happen? Every day? [ ] [ ] Several times per day? [ ] [ ] Every week? [ ] [ ] Other? If you have chest pain, where is it? (right, left, center, front, back, etc) Tobacco Use (Cigarettes) Yes No Have you ever smoked cigarettes regularly? (More than 20 packs of cigarettes in a lifetime, or more than one cigarette a day for one year.) [ ] [ ] Do you still smoke? [ ] [ ] Do you have a plan to quit? [ ] [ ] Do you want help to quit? [ ] [ ] How old were you when you first started regularly smoking cigarettes? If you stopped smoking completely, how old were you when you stopped? How many cigarettes per day do (did) you smoke on an average? How many years altogether have you smoked? Yes No Do you smoke cigars? [ ] [ ] Do you smoke a pipe? [ ] [ ] Do you chew tobacco? [ ] [ ] SR (09/13) 3
4 Past Tests Yes No Have you had a chest X-ray? [ ] [ ] When was the last time? Where? Have you had pulmonary function tests (breathing tests)? [ ] [ ] When? Where? Have you ever had a skin test for tuberculosis (TB) (PPD, mantoux or tuberculin test?) [ ] [ ] Positive Negative Unknown Have you had these immunizations (vaccinations)? (check if yes) Tetanus shot [ ] Hepatitis [ ] Pneumovax ( Pneumonia shot ) [ ] Influenza vaccine ( Flu shot ) [ ] Every year? [ ] Allergies Yes No Have you ever been told by a health care provider that you have allergies? [ ] [ ] Have you ever had allergy tests? [ ] [ ] When? Where? Have you ever had allergy shots? [ ] [ ] When? Have you ever been told you have hay fever? [ ] [ ] Environmental Allergies Substance (such as pollen, mold, eggs, food, animals, etc.) Symptoms (such as rash, trouble breathing, wheezing, etc.) Medicine Allergies (or medicines you cannot tolerate) Medicine Symptoms (such as penicillin, iodine, etc.) (such as rash, trouble breathing, nausea, vomiting, etc.) SR (09/13) 4
5 Current Medicines Prescription Medicines Name Amount Reason Over-the-counter medicines or any dietary, herbal, natural or vitamin supplements Name Amount Medical History Yes No Asthma [ ] [ ] Emphysema [ ] [ ] Pneumonia [ ] [ ] Tuberculosis [ ] [ ] Other lung diseases [ ] [ ] Treated for sinusitis (sinus infection) [ ] [ ] Postnasal drainage [ ] [ ] Nasal polyps [ ] [ ] Allergy to aspirin [ ] [ ] High blood pressure [ ] [ ] Heart failure [ ] [ ] Angina (chest pain) [ ] [ ] Heart attack [ ] [ ] Abnormal heart rhythm [ ] [ ] Other heart disease [ ] [ ] Other medical problems / hospitalizations (past or present): SR (09/13) 5
6 Surgeries (type and approximate date) Family History Mother: [ ] Alive - current age [ ] Died - age at death Medical problems/cause of death Father: [ ] Alive - current age [ ] Died - age at death Medical problems/cause of death Sisters: Number living Number died Medical problems/cause of death Brothers: Number living Number died Medical problems/cause of death Has anyone in your family (grandparents, aunts, uncles, brothers, sisters, parents, children) had any of these medical problems?: Asthma: Emphysema: Lung cancer: Blood clots in the lungs: Other lung diseases: Diabetes: Heart problems: High blood pressure: SR (09/13) 6
7 Other medical problems in your family that you think are important to include: What type of building do you live in? Apartment House Mobile home Other How long have you lived in your home? Age of your home years Are you aware of any water problems in your home? Heat: forced air hot water baseboard other (please specify) Air conditioning: central room none Pets: cats dogs birds other Neighborhood air pollution (chemical plant, factory, etc.) SR (09/13) 7
8 Review of Systems Check any current or chronic (long-lasting) problems. General: Fatigue (tiredness) Fever Night sweats Weight gain Weight loss Loss of appetite Eyes: Drainage/discharge Vision loss Ears, nose, mouth, throat: Ear drainage Hearing loss Nasal drainage Ringing in ears Facial pain Hoarseness Cardiovascular: Chest pain Pain in legs when walking Irregular heartbeat Swelling in legs Gastrointestinal: Abdominal pain Constipation Diarrhea Vomiting Heartburn Blood in stools Musculoskeletal: Joint swelling Muscle weakness Genitourinary: Burning with urination Frequency of urination Blood in urine Abnormal vaginal bleeding Respiratory: Cough Shortness of breath Wheezing Hematology: Easy bleeding Easy bruising Neurologic: Trouble with walking or balance Seizures Numbness and tingling Trouble with speech Headaches Decreased alertness Psychiatric: Anxiety Depression Endocrine: Hotter or colder than others Excessive thirst Excessive appetite Allergic/Immunologic: Food allergies Medicine allergies Seasonal allergies Frequent infections Skin: Itching Rashes SR (09/13) 8
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
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Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
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
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
New Sleep Patient Questionnaire. Name Age Date. General Medical History 1. Please list any surgeries you have had and their approximate dates:
1 John S. Kim, M.D., Diplomate ABSM Lawrence A. Lynn, D.O., FCCP 1251Dublin Rd. Columbus, Ohio 43215 (614) 297-7704 (614) 297-7705 New Sleep Patient Questionnaire Name _ Age Date General Medical History
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE
NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE Today s : Patient Name: DOB: Race White/Caucasian Black/African American Asian Native American Alaskan Native Native Hawaiian Pacific Islander Other: Preferred Language:
I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
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