Health Risk Analysis Form
|
|
|
- Rachel Richardson
- 5 years ago
- Views:
Transcription
1 Health Risk Analysis Form This health risk analysis form helps to identify positive and negative aspects of health behavior. Although many of the effects are based on real findings from large epidemiological investigations, the estimates are generalized and should not be taken too literally. Accurately predicting how long you will live or when you will die is impossible. Plus one (+1) represents a positive effect that could add a year to your life or life to your, and minus one ( 1) indicates a loss in the quantity or quality of life. A zero (0) indicates no shortening or lengthening of your longevity. If none of the categories listed for a factor apply to you, enter 0. Complete each section and record the totals in section VIII. Section I: Coronary Heart Disease () Risk Factors Cholesterol or total cholesterol to HDL ratio < >280 < > Blood pressure (choose your highest number for either value) < >100 Smoking Never Quit Smoke cigar or pipe or close family member smokes One pack of cigarettes daily Heredity No family history of One close relative over 60 with Two close relatives over 60 with One close relative under 60 with Body mass index (BMI, use table 11.8 on page 236) < * >40* *If waist is under 40 in. (102 cm) subtract one less (e.g., 2 or 4) Gender Female under 55 Female over 55 Two or more packs daily Two or more close relatives under 60 with Male Stocky male Bald, stocky male Stress Phlegmatic, unhurried, generally happy Ambitious but generally relaxed Sometimes harddriving, timeconscious, competitive Hard-driving, time-conscious, competitive (type A) Physical activity High intensity, 60 min most days Moderate, 30 min most days Moderate, min, 3 5 times per week Light, min,1 2 times per week TOTAL: I. risk factors Type A with repressed hostility Little or none
2 Health Risk Analysis Form (continued) Section II: Health Habits (Related to Good Health and Longevity) Breakfast Daily Sometimes None Coffee Coffee and doughnut Regular meals Three or more Two daily Not regular Fad diets Starve and stuff Sleep 7 8 hr 8 9 hr 6 7 hr >9 hr <6 hr Alcohol None Women 3/wk Men 1 2 daily 3 6 daily >6 daily TOTAL: II. Health habits Section III: Medical Factors Medical exam and screening tests (blood pressure, diabetes, glaucoma) Regular tests, see doctor when necessary Periodic medical exam and selected tests Periodic medical exam Sometimes get tests Heart No history of problems, self or family Some history Rheumatic fever as child, no murmur now Rheumatic fever as a child, have murmur Lung (including pneumonia and tuberculosis) No problem Some past problem Mild asthma or bronchitis Emphysema, severe asthma, or bronchitis Digestive tract No problem Occasional diarrhea, loss of appetite Frequent diarrhea or stomach upset Ulcers, colitis, gall bladder, or liver problems Diabetes No problem or family history Controlled hypoglycemia (low blood sugar) Hypoglycemia and family history Mild diabetes (diet and exercise) Drugs Seldom take Minimal but regular use of aspirin or other Heavy use of aspirin or other Regular use of mood-altering or psychogenic TOTAL: III. Medical factors No tests or medical exams Have ECG abnormality or angina pectoris Severe lung problems Severe gastrointestinal disorders Diabetes (insulin) Heavy use of mood-altering or psychogenic
3 Section IV: Safety Factors Driving in car <7,000 mi (11,000 mostly local 7,000 10,000 mi (11,000 16,000 local and some highway 10,000 15,000 mi (16,000 24,000 local and highway >15,000 mi (24,000 km) per year, highway and some local Using seat belts Always Most of time On highway only Seldom (<25%) Never (>75%) Risk-taking behavior (Motorcycle, skydive, mountain climb, fly small plane, etc.) Some with careful preparation >15,000 mi (24,000 km) per year, mostly highway Never Occasional Often Try anything for thrills TOTAL: IV. Safety factors Section V: Personal Factors Diet Low fat, low calories Balanced complex carbohydrate High protein, limited fat Extra calories, low carbohydrate Unknown. 1 2 Longevity lived past 90, parents past 80 lived past 80, parents past 70 lived past 70, parents past 60 Few relatives lived past 60 Fad diets and fat Few relatives lived past Love and marriage Happily married Married Unmarried Divorced Extramarital relationship(s) Education Postgraduate or master craftsman College graduate or skilled craftsman Some college or trade school High school graduate Job satisfaction Enjoy job, see results, room for advancement Enjoy job, see some results, able to advance Job OK, no results, nowhere to go Dislike job Social Have some close friends Have some friends Have no good friends Stuck with people I don t enjoy Race White or Asian Black or Hispanic American Indian TOTAL: V. Personal factors Grade school graduate Hate job Have no friends at all
4 Health Risk Analysis Form (continued) Section VI: Psychological Factors Outlook Feel good about present and future Satisfied Unsure about present or future Unhappy in present, don t look forward to future Depression No family history of depression Some family history, feel OK Family history and mildly depressed Sometimes feel life isn t worth living Anxiety Seldom anxious Occasionally anxious Miserable, rather not get out of bed Thoughts of suicide Often anxious Always anxious Panic attacks Relaxation Relax or meditate daily Relax often Seldom relax Usually tense Always tense TOTAL: VI. Psychological factors Section VII: For Women Only Health care Regular breast and Pap tests Occasional breast and Pap tests Never have exams Treated disorder Birth control pill Never used Quit 5 ago Still use, under 30 Use pill and smoke TOTAL: VII. For women only Untreated cancer Use pill, smoke, over 35 Section VIII: Scoring Summary You can now estimate your longevity. Add your total score from the previous sections to your normal life expectancy (from the chart below) to find your longevity estimate. If you would like to improve your longevity estimate, go back and decide on some lifestyle areas you would like to improve. Category I. risk factors II. Health habits III. Medical factors IV. Safety factors V. Personal factors VI. Psychological factors (+ or from previous sections) VII. For women only Total + = Total from sections I-VII Life expectancy (from the following table)
5 Life Expectancy EXPECTANCY (ALL RACES) Nearest age Male Female From NSCA, 2012, NSCA s essentials of personal training, 2nd ed., J. Coburn and M. Malek (eds.), (Champaign, IL: Human Kinetics). Adapted, by permission, from B. Sharkey and S. Gaskill, 2007, Fitness and health, 6th ed. (Champaign, IL: Human Kinetics), 64-68; Data from Life Expectancy from CDC, National Vital Statistics Reports, June 2010.
Executive Summary Report Sample Executive Report Page 1
Sample Executive Report Page 1 Introduction This report summarizes the primary health findings for those individuals who completed the Personal Wellness Profile (PWP) health assessment. Group health needs
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
Weight Loss- Medical History Form
Weight Loss- Medical History Form Name: Age: Sex: M F Family Physician: Phone: May we contact this practitioner? Yes No Present Status: 1. Are you in good health at the present time to the best of your
Name: Age: Sex: M F. 1. Are you in good health at the present time to the best of your knowledge? Yes No
Medical History Form Name: Age: Sex: M F Family Physician: Phone: Present Status: 1. Are you in good health at the present time to the best of your knowledge? Yes No 2. Are you under a doctor s care at
Byers Wellness Center- Patient Information for HCG Program. General Patient Information
1 Byers Wellness Center- Patient Information for HCG Program Welcome to Byers Wellness Center. We are excited to have you as one of our patients. In order for us to best serve you on your initial visit
Now is the time for a trimmer, healthier you.
Weight No More! Now is the time for a trimmer, healthier you. Medical Director: Peter Ruggiero, M.D Bariatric Physical Exam Name: Age: Date: Vital Signs: BP (sitting) Pulse Height (w/o shoes) inches Weight
PATIENT HEALTH HISTORY
Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
Single Married Divorced Widowed Male Female
Annual Physical Form General Information Name Birth Date Phone Email Address Street Address City State Zip Marital Status Gender Single Married Divorced Widowed Male Female Employment Information Position
Bariatric Surgery. Website: http//baybariatricsurgery.com
Bay Bariatric Surgery Kevin L. Huguet, M.D. General Surgery Laparoscopic Surgery Bariatric Surgery George Rossidis, M.D. General Surgery Minimally Invasive Surgery Bariatric Surgery Website: http//baybariatricsurgery.com
DIABETES SELF MANAGEMENT EDUCATION / NUTRITION COUNSELING INITIAL ASSESSMENT. NAME Today s Date
NAME Today s Date DATE OF BIRTH CONTACT INFORMATION: Home Number Cell phone number Work Number Okay to call at work? No Yes Answering machine No Yes Ok to leave message Your own personal Email Address
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
EGEA MEDICAL WEIGHT LOSS CENTER. Name: Age: Sex: M F. 6. History of Diabetes? Yes No At what age:
EGEA MEDICAL WEIGHT LOSS CENTER Medical History Form Name: Age: Sex: M F Primary Care Physician: Home Phone : Present Status: 1. Are you in good health at the present time to the best of your knowledge?
PATIENT HEALTH INFORMATION SHEET
. Norman J. Brodsky, M.D. Board Certified Michael D. Gauwitz, M.D. Diplomate, ABR Taghrid A. Altoos, M.D. Radiation Oncology Hiral K. Shah, M.D. PATIENT HEALTH INFORMATION SHEET NAME: DATE OF BIRTH: AGE:
Primary Medical Associates. Patient Information Sheet:" Patient Name Date of Birth " Mailing Address: " City State Zip " Phone# (H) SS# "
1 of 10 Patient Information Sheet: Patient Name Date of Birth Mailing Address: City State Zip Phone# (H) SS# Patient s Employer Phone# ==================================================================
Health History Questionnaire. Age Date of Birth Gender. Married Single Separated Divorced Widowed Partnership
Health History Questionnaire Name Date Age Date of Birth Gender Married Single Separated Divorced Widowed Partnership Live with: Spouse Partner Parents Children Friends Alone Please complete these next
Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
FHN Medical Weight Management Program
Date: Medical History Form Name: Date of Birth: Sex: M F Primary Healthcare Provider: Phone: Present Status: 1. Are you in good health at the present time to the best of your knowledge? Yes No 2. Are you
How to Prevent Heart Disease
How to Prevent Heart Disease Introduction Heart disease is the leading cause of death worldwide. You can reduce your risk of heart disease with healthy habits. This reference summary explains heart disease
Wellness Profile - Questionnaire
G1. G2. G3. WM1. WM2. WM3. EX1. Do you believe your current lifestyle: 1. Positively affects your health 2. Negatively affects your health 3. Does not affect your health 4. Not Sure Of all the possible
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
Lifestyle/Readiness for Change Assessment
Lifestyle/Readiness for Change Assessment This form asks you a variety of questions about your lifestyle habits. This questionnaire should take about 10 minutes. Fill in the information requested, or place
Personal Health Risk Assessment
Personal Health Risk Assessment The purpose of this assessment is to determine your risk of developing the degenerative diseases common among Americans. Although diagnostic testing can sometimes be important,
Name (Last Name, First Name): SSN #: Date of Birth: Age: Sex: M F Other. Address: Home phone: Work phone: Cell phone:
SCREENING APPLICATION NOTE: THIS APPLICATION MUST BE COMPLETED BEFORE YOU CAN ENROLL IN THE NEW DIRECTION (ND) SYSTEM. PLEASE ANSWER EVERY QUESTION. PLEASE PRINT CLEARLY. Date: Name (Last Name, First Name):_
Patient Medical History Form
Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear
12 Reasons. Why I Want to Reach My Goal Weight
WeightLossNYC, page 1 12 Reasons Why I Want to Reach My Goal Weight Name: Date: Before writing your reasons down, give them some thought. It is important that these 12 reasons be true personal goals and
Sample Well-being Assessment
Sample Well-being Assessment This assessment addresses the following eight categories, as well as the importance, readiness, and confidence in each category: Energy Stress Management Life Balance Weight
Here are a few ideas to help you cope and get through this learning period:
Coping with Diabetes When you have diabetes you may feel unwell and have to deal with the fact that you have a life long disease. You also have to learn about taking care of yourself. You play an active
SLRHC Cardiovascular Prevention Program - Cardiovascular Health Questionnaire
SLRHC Cardiovascular Prevention Program - Cardiovascular Health Questionnaire Last Name: First Name: Date of Birth: / / Today's Date: / / month day year month day year Personal History Sex : Male Female
Dr. Hall New Patient Paperwork Please fill out these forms completely
Dr. Hall New Patient Paperwork Please fill out these forms completely Date of Appointment Complete the enclosed packet and bring it to the appointment along with all X Rays, MRI disc and reports. Please
Please list current medications Include Herbal and over the counter medications Include dose and how many times a day drug is taken 1. 6.
Name Date Date of Birth Sex F M Allergies to Medications / Latex please include type of reaction Please list current medications Include Herbal and over the counter medications Include dose and how many
VIDEO WORKSHEET. Review: # Name: Hour: After viewing each segment, answer the following questions. Making Family Meals Happen
#300008 Name: Hour: VIDEO WORKSHEET Review: After viewing each segment, answer the following questions. Making Family Meals Happen 1. What is one of the most important keys to feeding well? 2. Children
New Patient History Patient Name: Age: Date of Birth:
New Patient History Patient Name: Age: Date of Birth: Is there a physician you would like us to send a letter about your visit/progress here? If yes, please provide their name, address & office phone number:
PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT
Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
Patient Medical History
Date: The PMA Metabolic and Bariatric Weight Management Center 410 West Linfield-Trappe Road, Suite 100 Limerick, PA 19468 (610) 495-2338 Patient Medical History Name: Date of Birth: Age: Female Male ALLERGIES:
Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:
Tel: (312) 694-7337 Women s Integrated Fax: (312) 695-0156 Pelvic Health Program 1.0: Basic Information Date of Birth: / / Age: Home Address: Preferred Language: English Spanish Other: Email address: Preferred
Re-Screening Medical History Questionnaire
Building Trades National Medical Screening Program Re-Screening Medical History Questionnaire Name: Address: _ City: _State: Zip Phone Number (include Area Code): Social Security # Date of Birth If female,
The Relationship between Healthy and Fit Personal Habits and Healthy and Fit Cultural Practices
The Relationship between Healthy and Fit Personal Habits and Healthy and Fit Cultural Practices Healthy and Fit Business Practices Page 1 The Relationship between Healthy and Fit Personal Habits and Healthy
Knowledge TO MEET THE EXTRODINARY CHALLENGES YOU ARE FACING TODAY YOU MUST DEMONSTRATE EXTRAODINARY BUSINESS PRACTICES:
Sharing Best Practices Knowledge TO MEET THE EXTRODINARY CHALLENGES YOU ARE FACING TODAY YOU MUST DEMONSTRATE EXTRAODINARY BUSINESS PRACTICES: The Relationship between Healthy and Fit Personal Habits and
PE2 Q1 #1 Hand-out & Worksheet 30 points. Exercise and Your Heart A Guide to Physical Activity
PE2 Q1 #1 Hand-out & Worksheet 30 points Exercise and Your Heart A Guide to Physical Activity Coronary heart disease remains the No. 1 cause of death and disability in the United States for both men and
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
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:
Please complete ALL 6 pages of the form in blue/black ink. Patient Acct # Provider # BMI # Height Weight
Please complete ALL 6 pages of the form in blue/black ink. Patient Acct # Provider # BMI # Height Weight f-25-n (08-07-13) ( 11-02-12) 0 10 Spine Questionnaire (continued) OFFICE USE ONLY Patient Acct
Nebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY
Nebraska Bariatric Medicine 8207 rthwoods Dr., Suite 101 Lincoln, NE 68505 MEDICAL HISTORY Name Today s Date The following page allows you to complete what we call a weight timeline. This is a very valuable
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D. PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC Name: Age: Sex: Male Female Occupation: Job description: Date: PLEASE ANSWER THE FOLLOWING QUESTIONS: Major
PERSONAL HISTORY CURRENT HEALTH CONDITION
PERSONAL HISTORY Name: Date S.S.# Address: City: State Zip code Home phone Cell Other: E-Mail Date of Birth Age Sex Male Female Business/Employer Address Type of Work Years Employed Check One Married Single
Name of Pa. tient: Last. First. per day) 50 mg. X-ray dye or. IV contract. Name (Last) (First) Address. City, state/ zip code
Division of Cardiology for the Academic Medical Center of the University of Texas Medical School at Houston NEW PATIENT HISTORY FORM Please complete and fax to 713-512-2245 Name of Pa tient: Last _ First
Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
Name: Age: Date: Accompanied by Relationship E-mail: @ MEDICAL BACKGROUND INFORMATION Please name the professionals that you have seen for this condition: Name Specialty Town Phone Who is your primary
People with HIV or AIDS are living longer, healthier lives. But, a lot of. 60% and 70% still smoke cigarettes.
HIV and Smoking People with HIV or AIDS are living longer, healthier lives. But, a lot of people with HIV or AIDS between 60% and 70% still smoke cigarettes. If you have HIV or AIDS and you smoke, you
The Johns Hopkins Diabetes Center JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT. Name: Marital Status: M S W SEP D
JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT Date: JHH # I. General Information Name: Marital Status: M S W SEP D Address: Phone: Home: Work: Email: Fax: Sex: M F Date of
New Patient Medical Questionnaire DATE:
New Patient Medical Questionnaire DATE: Patient Name: DOB: AGE: Other Physicians: Who can we thank for referring you to our practice? Pharmacy Name & Location:` Phone # CHIEF COMPLAINT What problems are
ALLERGIES 8. Have you ever had any allergic reaction (bad effect) to a medicine or shot?
Adult Health History Legal Name: First Last Name you like to be called: Date of Birth: Legal sex: Male Female X Gender: Woman Man Trans Woman Trans Man Non-binary Genderqueer Agender Not Listed: Filling
Health & Wellness Assessment. Name Date of Birth. List the names of any doctors, medical providers, nurses, or medical suppliers that you have:
1 Health & Wellness Assessment Name Date of Birth List the names of any doctors, medical providers, nurses, or medical suppliers that you have: Name Phone Services You Receive General Health In general,
Cancer Control Office YOUR GUIDE TO QUIT SMOKING
Cancer Control Office YOUR GUIDE TO QUIT SMOKING ARE YOU THINKING ABOUT QUITTING SMOKING? IF YOU ARE, CONGRATULATIONS FOR TAKING THIS IMPORTANT STEP! This brochure will help you: Set your own reasons to
Initial Client Questionnaire
Initial Client Questionnaire First Name: Middle Initial: Last Name: How did you hear about my services: Medical History Pregnant: Yes No Nursing: Yes No When was your last physical exam? What are your
My BluePrint Health Assessment. When completed, please return. Gender: o Male o Female Group No. City State Zip. Blood Pressure
My BluePrint Health Assessment When completed, please return. First Name - - Date of Birth (mm/dd/yyyy) Last Name Gender: o Male o Female Group No. BCBSAZ ID (You will need your BCBSAZ member card to complete
An Introduction to Bariatric Surgery
An Introduction to Bariatric Surgery What is bariatric surgery? Bariatric surgery is a treatment used to help people with obesity manage their health and weight. Why use surgery to manage obesity? Obesity
Please complete and return to the office prior to your appointment.
Please complete and return to the office prior to your appointment. Name: Last:, Today s Date: First: MI: Nickname: Date of Birth: Age: Sex: M F SSN: Parent/Legal Guardian (if the patient is a minor):
Legacy Weight and Diabetes Institute New Patient Information
Legacy Weight and Diabetes Institute New Patient Information Answering these questions will help your providers understand your health and how best to treat you. If you need help filling out this form,
Name: Date: Who referred you? Current Psychiatrist: Clinical Information:
LIFE HISTORY QUESTIONNAIRE Adult The purpose of this questionnaire is to obtain an understanding of your life experience and background. Then we can begin to develop a comprehensive treatment program suited
What You Will Learn to Do. Linked Core Abilities
Courtesy of Army JROTC U4C1L3 Components of Whole Health Key Words: Balance Behavior Calories Decision Fitness Metabolism Self-discipline What You Will Learn to Do Develop a plan for life-long health Linked
WELCOME TO UBMD FAMILY MEDICINE OF AMHERST. Thank you for selecting your Primary Care Physician with UBMD Family Medicine of Amherst.
WELCOME TO UBMD FAMILY MEDICINE OF AMHERST Thank you for selecting your Primary Care Physician with UBMD Family Medicine of Amherst. Some things to do before your visit Please call your health insurance
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
City: State: Zip: Age: Height: Current weight: Weight 6 months ago: Employer: Work #: Ext:
1 Last Name: First Name: Middle Initial: Address: Apartment #: City: State: Zip: Home #: Cell #: Email: How did you find us? Patient (who) : Doctor (who) : Staff (who) : Date of Birth: / / Gender (circle
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.
NOTICE TO OUR PATIENTS
SMG Chestnut Street, SMG Elm Street, SMG Mancos Valley, Southwest Walk-In Care, Southwest School-Based Health Center, SMG Market Street, SMG Orthopedics, SMG Pulmonary and Sleep Medicine, SMG General Surgery,
FAMILY MEDICINE New Patient Medical History Form
FAMILY MEDICINE New Patient Medical History Form Personal History : Name: Date of Birth / / (mm/dd/yyyy) Age Occupation Birthplace (City&Country) Marital Status (check one): Single Married Divorced Separated
SELF-REPORTING HEALTH HISTORY
SELF-REPORTING HEALTH HISTORY DATE: DEMOGRAPHIC INFORMATION : Age: Address: City: State: Zip Code: Work Phone: Home Phone: Fax Number: E-mail: Significant Other : Phone: CHIEF COMPLAINT - HISTORY OF PRESENT
Healthy Hearts, Healthy Lives Health and Wellness Journal
Healthy Hearts, Healthy Lives Health and Wellness Journal Healthy Hearts, Healthy Lives You Are in Charge You can prevent and control heart disease by making some lifestyle changes. Keeping your journal
Medicare Annual Wellness Visit Patient History
Grace Health Medicare Annual Wellness Visit Patient History Name Date Birthdate Languages Spoken Date of Last Wellness Visit Do you have an advance directive or living will? Yes Don t Know Want Information
Questions to ask your healthcare professional
Prepare to quit Get ready! Talk to your healthcare professional about how to quit Set a date for quitting. Choose a date that is within the next 2 weeks and make a strong commitment to quit on that day
SMOKING HISTORY INSTRUCTIONS
INSTRUCTIONS SMOKING HISTORY Please answer the following questions based on your experiences with smoking. Each question allows you to choose from several alternatives. Please select one of the alternatives
PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:
Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are
Schodack Internal Medicine and Pediatrics. Annual Physical-Female
Schodack Internal Medicine and Pediatrics Annual Physical-Female Please Fill out this form (or have your caregiver complete it) and discuss with your medical provider. Thank you! Please Mark the preferred
Patient Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
ID# Name. Today s Date DIABETES HISTORY. Michigan Diabetes Research and Training Center DH The University of Michigan - 1 -
ID# Name Today s Date DIABETES HISTORY Michigan Diabetes Research and Training Center DH2.0 1998 The University of Michigan - 1 - First, we would like to ask you about the health care you have received
Welcome to the Healthplex!
Welcome to the Healthplex! Program Please check program that applies to you. If unsure, please ask our staff. Aftercare Employee Health Pulmonary Rehab Lung Gym Cardiac Rehab Health Improvement Prenatal/Post-Partum
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
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVER S LICENSE NUMBER: STATE: ADDRESS:
NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVER S LICENSE NUMBER: STATE: EMAIL ADDRESS: MARITAL STATUS: ( ) SINGLE ( ) MARRIED ( ) DIVORCED ( ) WIDOWED ( )
AND OUR LOVE / HATE RELATIONSHIP WITH IT.
AND OUR LOVE / HATE RELATIONSHIP WITH IT. SHIFTWORK Nearly ¼ of the U.S. Work force does some form of shiftwork. Shiftwork allows for continuous services and production 24 hours a day, and is outside the
Top 20 ways to live longer
Top 20 ways to live longer How to increase your life expectancy Life expectancy for both men and women has continued to rise. To ensure that you are one of those living longer we have prepared a list of
PSYCHOLOGICAL EVALUTAION QUESTIONNAIRE
PSYCHOLOGICAL EVALUTAION QUESTIONNAIRE The purpose of this questionnaire is to obtain an understanding of your life experience and background which is part of the evaluation process. Please bring this
Some college. Native American/ Other. 4-year degree 13% Grad work
Access to Affordable Health Care Access to affordable care improves quality of life and health outcomes. Without affordable access to a doctor, residents are more likely to end up in expensive emergency
PATIENT REGISTRATION FORM. Last Name: First Name: Initial: Address: City: State: Zip Code: Date of Birth: / / Social: - - address:
TIMOTHY B. COLE, MD ALLISON TRAVIS, MD 7300 Eldorado Parkway, Ste 260, McKinney, TX 75070 Phone: 972-747-0440 / Fax: 972-747-0441 PATIENT REGISTRATION FORM Date: Last Name: First Name: Initial: Address:
BEHAVIORAL RISK FACTORS
EXAMPLES OF QUESTIONS IN AN HRA BEHAVIORAL RISK FACTORS PHYSICAL INACTIVITY/LACK OF EXERCISE How many days a week do you usually exercise? days per week On days when you exercise, for how long do you usually
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight:
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight: I Referring Doctor Complete Name of Referring Doctor Last Complete Address
Adult Initial Health History
Adult Initial Health History Name Today's Date First Middle Last Date of Birth Address Telephone Number (home)( ) (cell) ( ) (email address) Filling out this form Answering these questions will help your
Prediabetes 101. What is it and what can I do about it? Intermountainhealthcare.org/diabetes
Prediabetes 101 What is it and what can I do about it? Patient Education Intermountainhealthcare.org/diabetes What do you already know about prediabetes? Fact or Fiction? There are often no symptoms of
MGH Beacon Hill Primary Care New Patient Form
MGH Beacon Hill Primary Care New Patient Form For Office Use Only Date Reviewed By Name Date of birth Medical History Please check all that apply. Alcoholism Angina or heart attack Anorexia/bulimia Arthritis
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work)
Living Healthy , The Patient Education Institute, Inc. hp Last reviewed: 03/30/2017 1
Living Healthy Introduction Most diseases that cause disability and death among Americans can be prevented or delayed. Practicing healthy living habits and having regular medical screenings can help you
Patient Interview Form
Page 1 of 6 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Race Select
Are you a Christie registered patient? Yes No Have you had labs (lipid profile & basic metabolic panel) done within 6-9 months?
What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy or Danville Are you a Christie registered patient? Yes No Have you had labs (lipid
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?
Last Name: First Name: MI: 1. Have you recently had any major family changes: If yes, please explain:
Adult Medical Questionnaire Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Chiropractic Intake Form Name Date Address City State Date of Birth Age Phone Email Address Employer Emergency Contact Phone