This form is long! Please feel free to have the doctor or medical staff help you to complete it if you need any assistance at all.
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- Hortense Kelley
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1 Welcome! This form helps us to meet your medical needs and to provide the best service to you. If you have any questions or need assistance, please ask us. GENERAL PATIENT INFORMATION Name: Home Phone: Date of Birth: Gender: Female Male Cell Phone: Address: Work Phone: City: State: Zip: Preferred Method of Contact: Home Cell Work Occupation: EMERGENCY CONTACT INFORMATION Contact #1 Name: Relationship to You: Contact #1 Phone: Contact #2 Name: Relationship to You: Contact #2 Phone: INSURANCE ASSIGNMENT AND RELEASE Please make sure we have a copy of your insurance card. I hereby authorize payment directly to Medrthwest for all insurance benefits otherwise payable to me for services rendered. I am responsible for all charges not covered by insurance. Signature: Date: What brings you into the office today? This form is long! Please feel free to have the doctor or medical staff help you to complete it if you need any assistance at all. CURRENT HEALTH SUMMARY Please list any current medical issues, the date you first noticed the issue, and the name and specialty of the physician who treated you (if any): Current Medical Concerns Date of Onset Physician s Name Specialty List any current medications, including over-the-counter drugs, aspirin, vitamins and herbal preparations. I am on no medications. Medication Name Pill Size How Taken Medication Name Pill Size How Taken Medrthwest 901 Boren Avenue, Suite 1520 Seattle, WA Phone: Fax:
2 FAMILY MEDICAL HISTORY A close relative is a brother, sister, mother, father, or child. However, please consider any other relatives where you feel it may be helpful. Do you have a family history of heart attacks, stents, or bypass surgery? If yes, please list relative(s), t ype of heart disease, and the age when symptoms started. Have any of your close relatives had a history of stroke? If yes, please list the relative(s), and the age at which the stroke first occurred. Do you have a family history of colon polyps or colon cancer? If yes, please list the relative(s), type of colon issue, and the age when symptoms first appeared. Do you have a family history of diabetes? If yes, please list the relative(s) and the age at which diabetes first developed. Has anyone in your family had Alzheimer s Disease? If yes, please list the relative(s) and the age at which memory problems first occurred. Is there a family history of mental health problems that you feel is relevant? If yes, please list the relative(s) and describe the type of problem. Did you have a close relative with prostate cancer? (male patients only) If yes, please list the relative(s) and the age at which it first occurred. Do you have a close relative with osteoporosis or fractures? If yes, please list the family member(s), the type of fracture, and the age at which it first occurred. Any close relatives with a history of breast cancer or ovarian cancer? If yes, please list the family member(s), the type of cancer, and the age at which it first occurred. Have any relatives been tested for the BRCA-1 or BRCA-2 genes? If yes, what were the results? If you have other family health history that you feel is relevant describe the type of disease and the age at which symptoms first occurred.
3 ALLERGY INFORMATION List any allergies you have in the table below. I have no allergies of any kind. Food, Medication, or Insect Reaction Food, Medication, or Insect Reaction Additionally, please check if you are allergic to any of the following: Shellfish Contrast (Dye) Latex VACCINATION HISTORY Vaccine Date Vaccine Date Tetanus Flu Shot Pneumovax (pneumonia) Hepatitis A Hepatitis B Gardasil (HPV) Prevnar (PVC13) Other (?) Zostavax (shingles) Other (?) SURGICAL HISTORY Surgery or Procedure Date Name of Surgeon Outcome HEALTH MAINTENANCE Please enter the date of your last: Date Female patients only: Date Colonoscopy When was your last mammogram? Bone density scan (DEXA) When was your last pap smear? Treadmill test (stress test) Have you ever had an abnormal pap? Coronary calcium score If yes, when was it? Annual exam Did you undergo treatment? (please explain) Ultrasound test for aortic aneurysm PSA (male patients only)
4 REVIEW OF SYSTEMS In the last six months, have you experienced any of the following? Constitutional Genitourinary (Men) Respiratory # Loss of appetite # Slow urine stream # Asthma or wheezing # Fatigue # Up more than once per night to urinate # Emphysema (COPD) # Weight loss # Blood in the urine # Chronic cough # Weight gain # Trouble getting or maintaining erections # Shortness of breath # Unexplained fever # Lump or mass in the testicles # ne of these # ne of these # Hernia Neurological Eyes # Any sexual concerns # Headaches # Difficulty with vision # ne of these # Trouble with short term memory # History of eye surgery Genitourinary (Women) # Seizures # Glaucoma How many children have you had? # Numbness in the feet (neuropathy) # ne of these # Leakage of urine? # History of ADD or trouble with focusing? Ears, se, and Throat # Heavy or irregular periods # ne of these # Sleepy during the day # Vaginal pain, soreness, or dryness Psychiatric # Loud snoring at night # Blood in urine # Anxiety # Sleep Apnea # Hernia # Depression # Hearing loss # Any sexual concerns # Trouble sleeping # Frequent sinus or ear infections # ne of these # Panic attacks # ne of these # I had a hysterectomy # Specific fears (driving, elevators, etc) Heart...if so do you still have your ovaries? # Thoughts of hurting or killing yourself # Born with a heart defect Allergic or Immunologic # History of substance abuse # Have a pacemaker # Seasonal allergies # Prior suicide attempt # Heart murmur # Had chickenpox as a child # Psychiatric hospitalization # Take antibiotics before dental work # ne of these # Bipolar Illness # Heart valve problems Musculoskeletal # ne of these # High blood pressure # Arthritis Endocrine # High Cholesterol # Fibromyalgia # Thyroid problems # Stroke or TIA # Other joint pains # Severe menopausal symptoms # Abnormal Heart Rhythm # History of fractures. If so, what kind? # Diabetes # ne of these # Low testosterone # ne of these # ne of these
5 REVIEW OF SYSTEMS (continued from the previous page) In the last six months, have you experienced any of the following? Hematologic Gastrointestinal # Easy bleeding after surgery or dental work (ever in your life) # Hepatitis # History of anemia (low blood count) # Other liver disease # Iron deficiency # Blood in stool # ne of these # Heartburn Skin/Breast # Ulcer # Breast lump or mass # Unexplained abdominal pain # Unusual mole # Trouble swallowing solids or liquids # Skin cancer # Sensitivity to milk products # ne of these # Wheat allergy Oncology (Cancer) # Diverticulitis # History of any type of cancer? If so, what kind? # Polyps # ne of these TOBACCO, ALCOHOL, CAFFEINE, AND DRUG USE HISTORY Have you ever smoked? # packs / day # of years Do you chew tobacco? How many alcoholic drinks do you have in a typical week? # of drinks When did you quit? Did you drink more heavily in the past? Has anyone ever suggested that you cut down your drinking? How many cups of coffee do you drink daily? Any recreational drug use (mari juana, cocaine, and so forth)? If yes, please describe: # of drinks PERSONAL SAFETY Please check all that apply: I have a smoke detector in my home. I have a carbon monoxide detector at home. I use a cell phone while driving. (This is equally dangerous with or without a headset.) I keep firearms in my house. (If the answer is yes, we urge you to keep them locked or inside a locked compartment.) I wear a seat belt. I have a living will. I have a history of multiple falls I feel threatened by or afraid of someone close to me. I have a durable power of attorney for health care. (That person is.)
6 OTHER HEALTH INFORMATION I might benefit from some help with... Drinking a bit more than I should. Use of substances. Gambling. Improving my mental health. Weight loss. Loneliness or social isolation. Being too quick to anger. Troubled relationships. Getting more exercise. Life stress. Past issues or bad experiences that still bother me. Other: Do you exercise on a regular basis? If so, what activities and how many times per week? Do you follow any kind of special diet? If so, what? Are there any other medical concerns or questions you would like addressed? Anything else we should know to provide the best care and service to you? NOTES
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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
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
Patient Information: Date: Last Name: Street Address: City: SS #: First Name: Sex: M F Birthdate: Contact Information:
Welcome to PHC Family Medicine! We know you have a choice and appreciate your choosing us to provide care to your family. Dr. Frankhouser will be asking about your concerns today, but so that we can learn
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):
MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014
MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014 Name: Date of Birth: Today s Date: Where did you get healthcare before? May we request records? Y N (requires signed release)
Billings Clinic Urogynecology. Patient Name: Date of Birth: Visit Date:
Patient Name: Date of Birth: Visit Date: Please complete this questionnaire prior to arriving at the clinic so that we can be better prepared to address your particular health care needs. Provider who
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
New Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist
HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
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
Adult Health History New Patient
Adult Health History New Patient Today s Date PREFERRED NAME DATE OF BIRTH Reason for visit: What are your health goals for the next year? Previous Primary care Provider? Last visit? Specialists (Past
Patient Interview Form
Patient Interview Form Patient Information First Name: Last Name: Date of Birth: Age: Email Personal: Race Select one or more Referring Physician White Black or African Asian American Indian Native Hawaiian