Report of medical examination of a person for whom a Personal Health Record has been issued (Benzidine, etc.)
|
|
|
- Calvin Shaw
- 6 years ago
- Views:
Transcription
1 Form No.9 (Related to Article 57) (1) Report of medical examination of a person for whom a Personal Health Record has been issued (Benzidine, etc.) Date of birth: Cystoscopic test Normal Hyperemia, anemia, swelling, scar, ulcer, polyp, tumor Observation: bleeding, : Bloody urine (hematuria), frequent urination (pollakiuria), painful urination, difficulty in urination Pyelography Normal Abnormal Observation: Bloody urine (hematuria), frequent urination (pollakiuria), painful urination, difficulty in urination Microscopic examination of urinary sediment No cells detected Red blood cells, white blood cells, epidermal cells Cytologic test (Papanicolaou's test) Negative, suspicious, positive
2 Form No.9 (Related to Article 57) (2) Report of medical examination of a person for whom a Personal Health Record has been issued (pneumoconiosis) Pneumoconiosis control Pulmonary function test classification: 1. Height m Age Date of birth: Age ( ) Male / Female 2. Estimated lung capacity l Radiography test Examination date: Subjective symptoms Image 45 1.Photography date: 2. Film number: 3. Radiographic conditions: Intensifying screen Clinical chest examination Dyspnea Cough Phlegm Palpitation Others I, II, III, IV, V Opinion of physician: Opacity Category Granular opacity / Irregular opacity b. Classification of large opacity (A B C) KV c. Other observations mas 4. Radiographic appearance a. Clasiffication of small Image 46 Objective symptoms / Cyanosis Clubbed finger Adventitious sounds Others Type pqr (Pl/ l / /b / / / / / / b) (site: ) Primary examination Secondary examination Oxygen partial pressure Torr Torr Carbon dioxide partial pressure Torr Torr Alveolar-arterial oxygen difference. Torr. Torr Evaluation: F (Image 47) Subjective symptoms Close examination for tuberculosis Examination date Lung capacity l l FVC l l FEV1.0 l l FEV1.0/FVC. %. % %VC. %. % V25/height (m). l/sec/m. l/sec/m Examination date Blood sampling point Time from blood sampling to completion of analysis Examination for complications: Examination date: Tubercul osis bacteria Erythroc yte sediment ation rate Tuberculi n Evaluation: Smear: Culture: Radiogra Method: phy using a special Observat method 1 hour: 2 hours: mm x mm Examination for complications other than pulmonary tuberculosis Tuberculos is bacteria Phlegm Other findings Phlegm Date Volume Description Sputum Date cytodiagnosi (first day) s Observation Radiography using a special method Minutes Name and address of medical institution To Director of Labour Bureau Name of physician Smear: Culture: ml Smear: Exudate Culture: Method (spiral CT, others ( )) Observation Minutes Seal ml
3 Form No.9 (Related to Article 57) (3) Report of results of medical examination of a person for whom a Personal Health Record has been issued (chromic acid, etc.) Observation of radiography by using special methods Sputum cytodiagnosis Phlegm, cough, chest pain, nasal cavity ( ), skin ( ) Pathological examination of skin Phlegm, cough, chest pain, others ( ) Observation of nasal cavity Normal Abnormalities in nasal membrane, nasal septum perforation Observation of skin Direct radiography of chest Image 48
4 Form No.9 (Related to Article 57) (4) Report of medical examination of a person for whom a Personal Health Record has been issued (arsenic trioxide) Date of birth: Liver function test Blood test for red blood cells Measured arsenic content Hair ( ) Urine ( ) Phlegm, cough, stomatitis, diarrhea, constipation, weight loss, paresthesia, skin ( ), others ( ) Observation of radiography using special methods Sputum cytodiagnosis Phlegm, cough, anorexia, weight loss, paresthesia, others ( ) Observation of nasal cavity Pathological examination of skin Observation of skin Pigment anomaly (deposit, depigmentation), cornification, others ( ) Direct radiography of chest Image 49
5 Form No.9 (Related to Article 57) (5) Report of results of medical examination of a person for whom a Personal Health Record has been issued (coal tar) Observation of radiography using special methods Date of birth: Phlegm cytodiagnosis Phlegm, cough, chest pain, anorexia, skin ( ) Pathological examination of skin Phlegm, cough, chest pain, others ( ) Observation of skin Normal Dermatitis, acne-like lesion, melanoderma, verruca, gaseous spots Direct radiography of chest Image 50
6 Form No.9 (Related to Article 57) (6) Report of medical examination of a person for whom a Personal Health Record has been issued (bis(chloromethyl) ether) Observation of radiography using special methods Sputum cytodiagnosis Cough, phlegm, chest pain, weight loss Cough, phlegm, chest pain, weight loss Direct radiography of chest Image 51
7 Form No.9 (Related to Article 57) (7) Report of results of medical examination of a person for whom a Personal Health Record has been issued (beryllium) Physical examination of chest Lung ventilation function test Lung diffusing function test Electrocardiography Respiratory symptom, allergic symptom Dry cough, pharyngeal pain, throat irritation, chest pain, chest uneasiness, shortness of breath, palpitation, difficult breathing, malaise, anorexia, weight loss, others ( ) Observation of skin Lung capacity Beryllium content in urine or blood Skin patch test Hematocrit measurement Direct radiography of chest Image 52
8 Form No.9 (Related to Article 57) (8) Report of medical examination of a person for whom a Personal Health Record has been issued (benzotrichloride) Observation of radiography using special methods Sputum cytodiagnosis Cough, phlegm, chest pain, nasal discharge, epistaxis, anosmia, sinusitis, nasal polyp, skin ( ), others ( ) Head examination using radiography, etc. Blood test (including hemogram) Histopathological test of lymph nodes Cough, phlegm, chest pain, nasal discharge, epistaxis, anosmia, sinusitis, nasal polyp, swollen lymph node in neck, etc., others ( ) Histopathological test of skin Observation of skin Normal Verruca, pigment deposition, others ( ) Direct radiography of chest Image 53 Name of physician [seal]
9 Form No.9 (Related to Article 57) (9) Report of results of medical examination of a person for whom a Personal Health Record has been issued (vinyl chloride) Platelet count γ-gtp ZTT IGG LDH General fatigue, fatigability, anorexia, epigastric abnormalities, jaundice, black stools, pallor of finger or hand, hepatic disorder, pain, others ( ) Serum lipid Observation of radiography using special methods Headache, dizziness, tinnitus, general fatigue, fatigability, epigastric abnormalities, jaundice, black stools, pain in finger or hand, others ( ) Liver or spleen scintigram Enlargement of liver or spleen Hepatic function test Neuroclinical examination of central nervous system Direct radiography of chest Image 54
10 Form No.9 (Related to Article 57) (10) Report of results of medical examination of a person for whom a Personal Health Record has been issued (asbestos) Observation of radiography using special methods Sputum cytodiagnosis Smoking history, quit, currently smokes Cough, phlegm, shortness of breath, chest pain, others ( ) Cough, phlegm, shortness of breath, chest pain, others ( ) Direct radiography of chest Image 55
HASPI Medical Biology Lab 03
Patient 1001 is a 42-year-old female that is experiencing severe heartburn, abdominal pain, bloating, nausea, and vomiting. Ulcers Bleeding sores in the stomach or intestine Gallbladder Disease Gallstones
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
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,
Broward Oncology Associates, P.A. PATIENT INFORMATION
NAME: BIRTHDATE: AGE: LOCAL ADDRESS (Street city state zip): HOME TELEPHONE# CELL # SOCIAL SECURITY #: - - SEX MARITAL STATUS WHAT IS YOUR HT? WHAT IS YOUR WT? EMPLOYER WORK# SPOUSE'S NAME SPOUSE'S EMPLOYER
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
NEUROLOGICAL SURGERY, P.C.
NEUROLOGICAL SURGERY, P.C. PATIENT INFORMATION Name Date of Birth Age Address City Sate NY Zip Home ( ) - Cell ( ) - Work ( ) - Ext: Email Address _ Sex M F Soc. Sec. #: / / Single Married Widowed Separated
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
MARYWOOD UNIVERSITY PHYSICIAN ASSISTANT PROGRAM HISTORY, PHYSICAL, ASSESSMENT AND PLAN
MARYWOOD UNIVERSITY PHYSICIAN ASSISTANT PROGRAM HISTORY, PHYSICAL, ASSESSMENT AND PLAN PA: PRECEPTOR: MARYWOOD STAFF: PATIENT ID: AGE: SEX: DATE: Chief Complaint: History of Present Illness: 1 Medications:
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
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
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: MRN: Last Name: Date Of Birth: Contact Preference Email Telephone call- Work Telephone call - Home Email Please check one as your preferred
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
+ Color Change - + Hearing Loss - + Apnea - + Enuresis (urine - + Tremors - + Rash -
Review of Systems: 0-1 year old Constitution neg Eyes neg GI neg Neurological neg + Activity Change - + Eye Discharge - + Reflux - + Facial Asymmetry - + Appetite Change - + Eye Redness - + Vomiting -
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
IRIDOLOGY BREATHING. Compiled by. Campbell M Gold (2006) CMG Archives --()--
IRIDOLOGY BREATHING Compiled by Campbell M Gold (2006) CMG Archives http://campbellmgold.com Introduction The respiratory tract, which is also called respiratory system, is the complex of organs and structures
Please list any treatments you have previously had for current illness. (Physical Therapy, Surgery, Radiation, etc.)
Date: Patient Name: D.O.B Last First M.I History of Present Illness: What is the reason for your visit? Date symptom started? Please list any treatments you have previously had for current illness. (Physical
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
Mast Cell Activation Syndrome
Mast Cell Activation Syndrome Clinical Questionnaire Description Today s Date: Patient Name: Please indicate yes or no for the following symptoms and traits: (If you are not familiar with a particular
Pulmonary Pathophysiology
Pulmonary Pathophysiology 1 Reduction of Pulmonary Function 1. Inadequate blood flow to the lungs hypoperfusion 2. Inadequate air flow to the alveoli - hypoventilation 2 Signs and Symptoms of Pulmonary
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
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
PLEASE COMPLETE ALL SECTIONS OF THIS FORM
PLEASE COMPLETE ALL SECTIONS OF THIS FORM Patient Name: Date of Birth: Referring Doctor? (Name, telephone number and address) Chief Complaint: Why have you come here? How did it start? What are the symptoms?
Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
Welcome to About Women by Women
Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
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
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
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
What do you believe is causing your most important health concern?
Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to
Sick Call Screener Course
Sick Call Screener Course SOAP Note (1.3) 1.3-2-1 Enabling Objective 1.5 Document a patient encounter 1.3-2-2 SOAP Note Standard for documentation Designed to allow easy reference for follow-up care. (U.S.
JOHN MICHAEL ROACH, MD
GASTROENTEROLOGY JOHN MICHAEL ROACH, MD 520 N. 4 TH AVE. PASCO, WA 99301 Phone: (509) 546-8383 Name: Date of Birth: First Middle (full) Last m/d/yr Primary care provider: Referring physician: Local Pharmacy:
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
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
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
Respiratory Diseases and Disorders
Chapter 9 Respiratory Diseases and Disorders Anatomy and Physiology Chest, lungs, and conducting airways Two parts: Upper respiratory system consists of nose, mouth, sinuses, pharynx, and larynx Lower
Please 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
The exact cause of sarcoidosis is unknown. However, gender, race, and genetics can increase the risk of developing the condition:
What is sarcoidosis? Sarcoidosis is an inflammatory disease in which granulomas, or clumps of inflammatory cells, form in various organs. This causes organ inflammation. Sarcoidosis may be triggered by
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT
APPLICANT NAME: UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT REACTION ACCOM. LIGHT PUPILS EQUAL UNEQUAL FUNDI FIELDS OF VISION COLOUR (TEST USED) WITHOUT GLASSES NEAR FAR WITH GLASSES RIGHT
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
New Pulmonary Patient Questionnaire. Name Age Date. General Medical History
New Pulmonary Patient Questionnaire Name Age Date General Medical History 1 John S. Kim, M.D., Diplomate ABSM Lawrence A. Lynn, D.O., FCCP 1. Please list any surgeries you have had and their approximate
*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
For the Patient: Rituximab injection Other names: RITUXAN
For the Patient: Rituximab injection Other names: RITUXAN Rituximab (ri tux' i mab) is a drug that is used to treat some types of cancer. It is a monoclonal antibody, a type of protein designed to target
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your
MEDICAL QUESTIONNAIRE (male)
MEDICAL QUESTIONNAIRE (male) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501/502 Fax: 01 2780248 The appointment comprises of a discussion about this questionnaire and a subsequent
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
Cardiovascular Genetics Clinic Vascular Questionnaire
Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Primary Care Physician: Why have you been referred for a Cardiovascular Genetics Appointment? Have you had a genetics evaluation? If
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
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
Chapter 16. Vocabulary. Name Class Date
Chapter 16 Vocabulary plasma congenital larynx hemoglobin anemia bronchitis arteries leukemia pneumonia capillaries Hodgkin s disease pleurisy veins respiration asthma platelets diaphragm sinusitis lymph
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
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
THE OB/GYN CENTRE NEW PATIENT HISTORY
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
T- Timing- concise vs. complete and thorough, depending on need of presenter and audience. E- Elicit- ask for feedback- more information needed? Less?
Review of STAGE presentation framework (from umass.macy.edu, revised Alicia Monroe, MD from 2005 STFM) S- style organization, sequencing adequate to build a case for your diagnosis or a story T- Timing-
MISSOURI SPINE INSTITUTE John D. Spears, D.O.
MISSOURI SPINE INSTITUTE John D. Spears, D.O. : / / Patient Name: Office Use Only Right/Left Handed BP: / Pulse: Height: Weight: BMI: Primary Care Physician: Cardiologist: of Birth: / / Age: Sex: M F Please
Symptom Review (page 1) Name Date
v2.4, 2/13 JonathanTreasure.com Botanical Medicine & Cancer Herb Drug Interactions Herbalism 3.0 Symptom Review (page 1) Name Date INSTRUCTIONS Please read each section below carefully and, after each
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
Clermont Medical Center
Clermont Medical Center Stephen M. Asmann, M.D. 1135 Lake Avenue, P.O. Box 121009 Carol Takis, PA-C Memory Crowley, D.O Clermont, Florida 34712-1009 Sherri Sartin, PA-C Christopher Guzik, D.O. (352) 394-4035
New Patient Information & Consents
New Patient Information & Consents Name: DOB: SSN: Gender: Address: City: State: Zip: Home #: Cell #: Other#: Employment Status: Occupation: Email Address: Marital Status: S M D W How did you hear about
The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION
The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION Name: Email: Daytime Phone Number: Date of Birth: / / Age: How did you hear
HD CLINIC MEDICAL HISTORY FORM
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
Instructions: Please bring these forms to your Physical Examination & TB Test and have the Doctor fill them out. (Where applicable)
Instructions: Please bring these forms to your Physical Examination & TB Test and have the Doctor fill them out. (Where applicable) 1. The physician s examination certification form. Ask your doctor to
Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
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
Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency.
GENERAL SURGICAL ASSOCIATES A practice of Lehigh Valley Physician Group Suite 208 ~ 1240 S. Cedar Crest Boulevard ~ Allentown, PA 18103 Phone: (610) 402-9780 PLEASE COMPLETE THIS FORM PRIOR TO YOUR VISIST
1. Have you ever had or now have: 2. Have you ever had or now have:
1. Have you ever had or now have: 2. Have you ever had or now have: Yes No Please Check each item no blanks CARDIOVASCULAR Yes No Often Seldom 1. Chronic or frequent colds 1. Shortness of breath with normal
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Last Name: First Name: Date Form Completed: Referring Physician: Address: City: Sex: Marital Status: Race: Age: Married Caucasian Single Male Divorced African American Hispanic
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
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:
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name:
Eastern Body Therapy
2310 Eastern Body Therapy 6th Avenue San Diego, CA 92101 (619)772-4002 Personal Information Name Date of injury/illness Address: Apt. City State Zip Home phone: ( ) Work Phone: ( ) E-mail: Social Security
Part 1 : Personal Information (This part is to be completed by the applicant)
MEDICAL REPORT FOR FOREIGN WORKER FOR EMPLOYMENT IN BRUNEI DARUSSALAM (in accordance with The Infectious Diseases Order; Immigration Act and Labor Act of the Statutes of Brunei Darussalam) photo Accreditation
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
Women s and Men s Health Intake Form Comprehensive Physical Therapy Center
Name: (Last, First) DOB: Date: Age: Referring Physician: Next Physician Appointment: Today s visit: What is the main reason you came to the office today? When did it start? What treatments have you had
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
Clinical Radiological Pathological Conference
Clinical Radiological Pathological Conference CASE 1: A 59-year-old female Housekeeper Live in Phuket, Thailand Progressive dyspnea for 1 year Present illness 1 year PTA : She developed dyspnea on exertion
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,
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
Occupational Cancer. By : Dr. Aliraza Safaiyan M.D. Occupational Medicine Specialist
Occupational Cancer By : Dr. Aliraza Safaiyan M.D. Occupational Medicine Specialist Introduction Cancer is a leading cause of death worldwide, with 12.7 million new cases and 7.6 million deaths in 2008.
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:
DNA CENTER New Patient Information
DNA CENTER New Patient Information Name Email: Address City State Zip Home Phone Work Cell Phone Social Security Number Date of birth Gender ( Male/Female) Age Please Circle: Hispanic/Latin or Non Hispanic/Latin
Health Questionnaire
Patient Name Date of Birth Thank you for choosing Southern Cancer Center for your care. To help us best prepare for your appointment, please complete this form and bring it to your appointment. If you