Premier Internal Medicine of Alpharetta, PC
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1 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 Zip Code Home Phone Cell Phone Work Phone Race & Ethnicity Primary Language Employment Status Employed Self-Employed Unemployed Disabled Retired Student Occupation Address Emergency Contact (Name, Relationship, Phone) PHARMACY INFORMATION Name Pharmacy Phone # Pharmacy Address INSURANCE INFORMATION Primary Insurance Company Phone # ID/Subscriber # Group # Subscriber Name Relationship to patient Subscriber SSN Subscriber DOB Secondary Insurance Company Phone # ID/Subscriber # Group # 1
2 Name Current Medications DOB: Please include all Prescription, Over the Counter, Herbal Medications & Supplements. Medication Dose Frequency Allergies? Yes or No Please list all medications AND reactions Past Medical History Please list diagnosis (i.e. Diabetes, Hypertension, ect.), age/year at time of diagnosis Past Surgical History Family History 2
3 Father o Alive, age o Deceased, age Cause of Death Mother o Alive, age o Deceased, age Cause of Death Siblings # of Brothers # of Sisters Children # of Sons # of Daughters o Prostate Cancer o Testicular Cancer o Breast Cancer o Cervical Cancer o Ovarian Cancer o Breast Cancer o Cervical Cancer o Ovarian Cancer o Prostate Cancer o Testicular Cancer 3
4 REVIEW OF SYSTEMS CONSTITUTIONAL O CHANGES IN APPETITE O NIGHT SWEATS O FEVER/CHILLS O RECENT WEIGHT LOSS/GAIN O FATIGUE SKIN O CHANGE IN EXISTING SKIN LESION O NEW RASH O NEW SKIN LESION EYES O RECENT VISION CHANGES O DOUBLE VISION O EYE PAIN O EYE EXAM O EAR, NOSE, THROAT O LOSS OF HEARING O SNORING O TROUBLE SWALLOWING O DENTAL EXAM O ALLERGY/IMMUNOLOGY O SEASONAL ALLERGIES O FOOD ALLERGIES HEMATOLOGIC/LYMPHATIC O EASY BRUISING O ENLARGED LYMPH NODES CARDIOVASCULAR O CHEST PAIN O PALPITATIONS O FAINTING O DIFFICULTY BREATHING WHEN LAYING FLAT O LEG SWELLING O LEG PAIN WHEN WALKING RESPIRATORY O WHEEZING O SHORTNESS OF BREATH O COUGH O COUGHING UP BLOOD GASTROINTESTINAL o HEARTBURN o CONSTIPATION o CHRONIC DIARRHEA o CHANGE IN BOWEL HABITS o NAUSEA/VOMITING o BLOOD IN STOOL GENITOURINARY o BLOOD IN URINE o URINARY INCONTINENCE o OVERACTIVE BLADDER ENDOCRINE o HEAT INTOLERANCE o COLD INTOLERANCE o EXCESSIVE URINATION o DIMINISHED SEX DRIVE MUSCULOSKELETAL o JOINT PAIN, REDNESS, SWELLING o MUSCLE PAIN NEUROLOGICAL O HEADACHES O NUMBNESS O TINGLING PSYCHIATRIC o ANXIETY o DEPRESSION o INSOMNIA WOMEN S HEALTH o HEAVY/IRREGULAR PERIODS o BREAST LUMPS/NIPPLE DISCHARGE o MENOPAUSE o PAINFUL SEXUAL INTERCOURSE o POSTMENOPAUSAL BLEEDING MEN ONLY o ERECTILE DYSFUNCTION o TESTICULAR PAIN/MASS o WEAK STREAM 4
5 Social History Marital Status Single Engaged Married Separated Divorced Widowed Occupation Are you sexually active? Yes No Tobacco Use Yes or No Alcohol Use Yes or No Illicit Drug Use Men Women Both If Current Smoker: # Packs Per Day Years If Former Smoker: # Packs Per Day Years Quit Date If yes, how much and how often? Healthcare Maintenance Please list date of exam/procedure, performing physician, practice and location. Mammogram PAP Smear Bone Density Colonoscopy Prostate/Rectal Exam Immunizations Influenza (Flu) Gardasil (HPV) Hepatitis B,, Tetanus/Tdap (every 10 years) Pneumovax 23 Prevnar 13 MMR (Measles/Mumps/Rubella) Zostavax or Shingrix (Shingles) 5
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
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Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression
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HD CLINIC MEDICAL HISTORY FORM Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the questions below as best as you can. If you need assistance, a caregiver/companion
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PATIENT INTAKE AND HISTORY FORM (Please print) Name Date of Birth Race: American Indian or Native Alaskan Asian Black/African-American Native Hawaiian or Other Pacific Islander White Refused to report/unreported
More informationPlease be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
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PERSONAL PROFILE NAME: AGE: NAME YOU WOULD LIKE US TO USE: OCCUPATION: MARITAL STATUS: GYNECOLOGICAL HISTORY LAST MENSTRUAL PERIOD (FIRST DAY): AGE PERIOD BEGAN: PRESENT BIRTH CONTROL PAST METHODS OF BIRTH
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