Hilton Head ENT, Allergy, Sinus Hearing Center
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- Elisabeth Snow
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1 Name: DOB: Page 1 of 6 ** *********************** Past Medical History ********************** Cancer: Bone Cancer: Brain Cancer: Breast Cancer: Cervical Cancer: Chronic Lymphocytic Leukemia Cancer: Colon Cancer: Endometrial Cancer: Esophageal Cancer: Head or Neck Cancer: Leukemia Cancer: Liver Cancer: Lung Cancer: Lymphoma Cancer: Myeloma Cancer: Ovarian Cancer: Prostate Cancer: Pancreas Cancer: Sarcoma (Soft Tissue) Cancer: Skin - Basil Cell Carcinoma Cancer: Skin - Melanoma Cancer: Skin - Merkel Cell Carcinoma Cancer: Skin - Squamous Cell Carcinoma Cancer: Other Cardio: Arrhythmia Cardio: Atrial Fibrillation Cardio: Cardiomyopathy Cardio: Congestive Heart Failure Cardio: Coronary Artery Disease Cardio: Hyperlipidemia/High Cholesterol Cardio: Hypertension/High Blood Pressure Cardio: Myocardial Infarction/Heart Attack Cardio: Valve Disease: Valve prolapse, stenosis, or leaky valve Cardio: Other Endocrine: Diabetes: Type 1 Type 2 Endocrine: Pituitary Adenoma or other pituitary problem Endocrine: [ ]Hypothyroidism [ ]Hyperthyroidism Endocrine: Other General: Eating disorder General: Obesity General: Sexually Transmitted Infection GI: Barrett's Esophagus GI: Cholecystitis (gallbladder disease) or gallstones GI: Diverticulitis GI: Diverticulosis GI: Hemorrhoids GI: Incontinence GI: Inflammatory Bowel disease GI: Irritable Bowel Syndrome GI: Liver Disease: Auto-Immune Hepatitis GI: Liver Disease: Hepatitis GI: Liver Disease: Hepatitis A GI: Liver Disease: Hepatitis B GI: Liver Disease: Hepatitis B GI: Liver Disease: Sclerosing Cholangitis GI: Reflux/GERD GI: Other Uro: BPH (enlarged prostate) Uro: End stage renal disease (kidney failure) Uro: Incontinence Uro: Kidney Stones Uro: Recurrnet urinary tract infections Uro: Urinary/kidney reflux Uro: Other Ob/Gyn: Endometriosis Ob/Gyn: Fibroids Ob/Gyn: HPV (Papilloma virus/warts) Ob/Gyn: Polycystic ovary disease Ob/Gyn: pregnancy history Ob/Gyn: Other Immuno: HIV Immuno: Immunodeficiency Immuno: Other Lymph: Anemia Lymph: Bleeding Disorder/Hemophilia Lymph: Blood Clotting Disorder Lymph: Neutropenia (low white blood count Lymph: Sickle Cell anemia Lymph: Thrombocytopenia (low platelets) Lymph: Other Ortho: Arthritis
2 Name: DOB: Page 2 of 6 ** Past Medical History - continued Ortho: Degenerative joint disease Ortho: Osteoporosis Ortho: Spinal Stenosis Ortho: Other Neuro: ALS Neuro: Alzheimer's Neuro: Autism Neuro: Cerebral (brain) aneurysm Neuro: Cerebral Palsy Neuro: CVA/Stroke Neuro: Dementia Neuro: Developmental delay Neuro: Headaches Cluster Neuro: Headaches Migraine Neuro: Headaches Muscular Tension Neuro: MS Neuro: Parkinson's Neuro: Seizure Neuro: Other Ophth/Opt: Blindness Ophth/Opt: Macular degeneration Ophth/Opt: Cataracts Ophth/Opt: Glaucoma Ophth/Opt: Detached retina Ophth/Opt: Other Psych: Anxiety Psych: Bipolar disorder Psych: Depression Psych: Personality Disorder Psych: Psychosis Psych: Schizophrenia Pulm: Asthma Pulm: Bronchiectasis Pulm: COPD Pulm: Cystic Fibrosis Pulm: Emphysema Pulm: Obstructive Sleep Apnea (OSA) Pulm: Pulmonary Embolism Pulm: Pulmonary Fibrosis Pulm: Pulmonary Hypertension Pulm: Other Rheum: Auto-immune disorder Rheum: Fibromyalgia Rheum: Gout Rheum: Lupus Rheum: Rheumatoid Arthritis Rheum: Scleroderma Rheum: Sjorgren's syndrome Rheum: Other Vasc: Peripheral artery disease Vasc: Carotid stenosis Vasc: Abdominal aortic aneurysm Vasc: Thoracic aortic aneurysm Vasc: Other ** *** Past Surgeries - Have you had any surgeries on the following organs *** Abdominal/GI: Abdominoperineal resections Abdominal/GI: Appendectomy Abdominal/GI: Bariatric surgery Abdominal/GI: Bowel resection Abdominal/GI: Cholecystectomy (gallbladder) Abdominal/GI: Colectomy - Colon resection Abdominal/GI: Colectomy - Diverticulitis Abdominal/GI: Colectomy - Inflammatory bowel Abdominal/GI: Colostomy Abdominal/GI: Esophagectomy Abdominal/GI: Exploratory bowel surgery Abdominal/GI: Gastrectomy (stomach resection) Abdominal/GI: Hepatectomy (liver resection) Abdominal/GI: Hemorrhoidectomy Abdominal/GI: Hernia repair Abdominal/GI: Liver Shunt Abdominal/GI: Liver transplant Abdominal/GI: Low anterior resection Abdominal/GI: Pancreas resection Abdominal/GI: Splenectomy Abdominal/GI: Other Breast: Lumpectomy (Both Breasts) Breast: Lumpectomy (Left Breast) Breast: Lumpectomy (Right Breast) Breast: Mastectomy (Both Breasts) Breast: Mastectomy (Left Breast)
3 Name: DOB: Page 3 of 6 Breast: Mastectomy (Right Breast) Breast: Other Cosmetic: Breast augmentation Cosmetic: Breast reduction Cosmetic: Eyelid (blepharoplasty) Cosmetic: Facelift Cosmetic: Liposuction Cosmetic: Rhinoplasty Cosmetic: Tummy tuck Cosmetic: Other Heart: Biological Valve Replacement Heart: Coronary artery bypass surgery (CABG) Heart: Heart transplant Heart: Mechanical Valve Replacement Heart: Pacemaker Heart: PTCA (Percutaneous transluminal coronary angioplasty) Heart: Thoracic aortic aneurysm repair Heart: Other Lymph: Lymph node biopsy (specify location) Lymph: Other Neurosurgery: Craniotomy Neurosurgery: Pituitary Neurosurgery: Spine - Discectomy Neurosurgery: Spine - Fusion Neurosurgery: Spine - Hardware Neurosurgery: Spine - Laminectomy Neurosurgery: Tumor removal Neurosurgery: VP shunt Neurosurgery: Other Ob/Gyn: Bilateral tube ligation (tube tie) Ob/Gyn: Caesarean section Ob/Gyn: Dilation and curettage (D&C of uterus) Ob/Gyn: Hysterectomy - Caesarean section Ob/Gyn: Hysterectomy - Cervical cancer OB/Gyn: Hysterectomy - Uterine cancer Ob/Gyn: Oophorectomy (ovary resection) Ob/Gyn: Tubal Ligation Ob/Gyn: Other Ophth/Opt: Cataract surgery Ophth/Opt: Corneal surgery Ophth/Opt: Glaucoma surgery Ophth/Opt: Injections Ophth/Opt: Lasik Ophth/Opt: Lid Ophth/Opt: Macular hole Ophth/Opt: Retinal detachment repair Ophth/Opt: Laser retinal surgery Ophth/Opt: Other Ortho: Carpal tunnel Ortho: Hip arthroscopic surgery Ortho: Hip replacement Ortho: Knee arthroscopic surgery Ortho: Knee replacement Ortho: Shoulder arthroscopic surgery Ortho: Shoulder replacement Ortho: Surgical fracture repair Ortho: Tumor resection Ortho: Other Pulm: Lung transplant Pulm: Pleurodesis Pulm: Pneumonectomy (lung resection) Pulm: Other Skin: Basal Cell Carcinoma Skin: Melanoma Skin: MOHs resection Skin: Skin Biopsy Skin: Squamous Cell Carcinoma Skin: Wide local resection Skin: Other Uro: Cystectomy Uro: Implant Uro: Kidney stone removal Uro: Kidney transplant Uro: Nephrectomy (kidney resection) Uro: Orchiectomy (testicle resection) Uro: Prostatectomy - Prostate Cancer Uro: Prostatectomy - TURP Uro: Other Vascular: Abdominal aortic aneurysm repair Vascular: AV shunt (for dialysis access) Vascular: Carotid endarterectomy Vascular: Vascular bypass (leg vessels) Vascular: Other
4 Name: DOB: Page 4 of 6 ** ************************* Pediatric History ************************ Gestational Age at birth in weeks Birth Weight: lbs oz Forceps Delivery? Yes No Maternal Illness during pregnancy: ** **Medications with dosage / how often / route - OR YOU MAY PROVIDE YOUR OWN LIST ** ********** Medication / Drug Allergies ************ ** ******************** ENT Disease History ******************** Cancer: Head and neck Cancer - specify location Cancer: Lymphoma, neck nodes Cancer: Sinus or nasal cavity Cancer: Skin - basal cell carcinoma Cancer: Skin - Melanoma Cancer: Skin - other type - specify Cancer: Skin - squamous cell carcinoma Ear: Acoustic neuroma Ear: Cholesteatoma Ear: Hearing loss Ear: Mastoiditis Ear: Other Ear: Otitis externa (swimmer's ear) Ear: Otitis media (middle ear infection) Ear: Otosclerosis Ear: Tinnitus (ringing or other noise of the ear) Ear: Vertigo General: Facial fractures General: Other General: reflux Larynx/trachea: Papillomas Larynx/trachea: Subglottic stenosis Larynx/trachea: Tracheal stenosis Larynx/trachea: Vocal cord nodules Larynx/trachea: Vocal cord paralysis Larynx/trachea: Vocal cord polyps Larynx: Other Nasal: Deviated septum Nasal: Epistaxis (nose bleeds) Nasal: Loss of smell Nasal: Nasal fracture Nasal: Nasal obstruction Nasal: Polyps Nasal: Rhinitis (allergies) Nasal: Septal perforation Nasal: Sinusitis Nasal: Turbinate hypertrophy Nasal: Other Neck: Branchial cleft cyst Neck: Hyperparathyroidism Neck: Neck mass Neck: Parotid tumor Neck: Sialoadenitis (infected or inflamed salivary gland) Neck: Sialolithiasis (stone of the salivary gland) Neck: Thyroglossal duct cyst Neck: Thyroid nodules Neck: Other Oral: Sleep apnea Oral: Tonsillitis Oral: Ulcers Oral: other
5 Name: DOB: Page 5 of 6 ** ******************** ENT Surgical History ******************** Ear: Acoustic neuroma resection Ear: Tympanoplasty (repair ear drum) Ear: Mastoidectomy Ear: Other Ear: Myringotomy and tubes (specify ear) Head and neck: Lymph node biopsy Ear: Myringotomy (specify ear) Head and neck: Neck dissection Ear: Otoplasty Head and neck: Parathyroidectomy Ear: Stapedectomy Head and neck: Parotidectomy Head and neck: Skin graft Head and neck: Resection in mouth or throat Head and neck: Skin resection Nose: Nasal fracture repair Head and neck: Submandibular gland excision Nose: Rhinoplasty Head and neck: Thyroglossal duct cyst excision Nose: Septoplasty Head and neck: Thyroidectomy Nose: Turbinate reduction Head and neck: Tracheotomy Nose: Other Head and neck: Other Throat: Adenoidectomy Nose: Balloon sinuplasty Throat: Sleep apnea surgery - (UPPP) Nose: Endoscopic sinus surgery Throat: Tonsillectomy Throat: Other ** ******************** ENT Family History ******************** Otitis Media Throat Cancer Sinusitis Thyroid Cancer Smoking Thyroid Disease Other ** ******************** ENT Pediatric History ******************** Cleft Lip Cleft Palate Otitis Media (ear infections) Other ** ************************* Social History ************************ Smoking Status: Never Smoker Former Smoker Current every day smoker Current some day smoker (cigarettes) Current some day smoker (tobacco) Cigar smoker Heavy smoker Light smoker Started smoking when? Quit smoking when? Number of packs per day?
6 Name: DOB: Page 6 of 6 Alcohol Use: None Less than 1 drink per day 1-2 drinks per day 3 or more drinks per day What is your caffeine use? Never Few times a week [ ] Few times a month Several times a day How often do you exercise? Never Once a day Few times a week Few times a month Patient feels safe at home Patient feels UNSAFE at home Pets at home Child attends daycare Occupation and workplace: Place of residence In own home Assisted living community Full time care facility ************************* Family History ************************ Cancer: Type Cancer: Type Diabetes: [ ] Type I [ ] Type 2 Heart Disease : Stroke: Other:
Lymph: Anemia Cancer: Bone. Endocrine: Other. Lymph: Bleeding Cancer: Brain. General: Eating disorder. disorder/hemophilia Cancer: Breast
Medical History: Please check off any of the following medical conditions that you currently have: NONE Endocrine: Lymph: Anemia Cancer: Bone General: Eating disorder Lymph: Bleeding Cancer: Brain General:
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Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
David W. Wimberley, MD
Please fill out these forms completely! We know that filling out these forms can be difficult, but please complete them carefully. Your accurate responses will give us a better understanding of you and
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.
CUMULATIVE ILLNESS RATING SCALE (CIRS)
CUMULATIVE ILLNESS RATING SCALE (CIRS) The CIRS used in this protocol is designed to provide an assessment of recurrent or ongoing chronic comorbid conditions, classified by 14 organ systems. Using the
VASCULAR SURGERY PATIENT HEALTH HISTORY
VASCULAR SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications? To
Primary Care Physician: Have you had physical therapy during this calendar year? Yes No
Name: Date of Birth: Primary Care Physician: Referring Physician: Have you had physical therapy during this calendar year? Yes No Have you had occupational therapy during this calendar year? Yes No If
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy This form must be scanned into the medical record. Do not remove from clinic. UWMC Women s Health Care Center & SCCA Women s Cancer Center
List of Qualifying Conditions
List of Qualifying Conditions Cancer Conditions 1) Adrenal cancer 2) Bladder cancer 3) Bone cancer all forms 4) Brain cancer 5) Breast cancer 6) Cervical cancer 7) Colon cancer 8) Colorectal cancer 9)
PATIENT HISTORY FORM
PATIENT HISTORY FORM Date: Page 1 of 5 Last Name: First Name: Middle Initial: Referred By: Age: Primary Care Doctor: Please provide name(s) of other physician(s) that you have visited within the last year:
Primary (First) Complaint and Location
Name: : File #: Case Type: Sex: Birth : Age: Social Security #: Address: Residence and Mailing City State Zip Code Home Phone: Mobile Phone: Email: Occupation: Employer: Work Phone: Marital Status: S M
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
DEMOGRAPHICS. Female Weight: lbs
DEMOGRAPHICS Date of Birth: Age: years Gender: Male Height: inches Female Weight: lbs Handed: Right BMI: Left Ambidextrous Race: choose only one Ethnicity: Marital Status: African American / African Heritage
Pharmacy Name/Location/Phone number:
Pharmacy Name/Location/Phone number: Family Physician Name: Phone: Address: Referring Physician Name: Phone: Address: First Emergency Contact: Relationship: Home/cell phone: Work phone: Second Emergency
Medical History Record
Medical History Record Today s For faster service, please complete the following form prior to arriving at our office. FIRST NAME: M.I. LAST NAME: Address City State Zip Code D.O.B. Sex: M F Email Home
New Patient Medical History Form
New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
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
Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Circle Preferred Phone Number Home
Salt Lake Orthopaedic Clinic Initial Visit Form
Salt Lake Orthopaedic Clinic Initial Visit Form Name: Today s Date: Date of Birth: Age: Height: Weight: Handedness (R/L): Referring Physician: Primary Care Physician: Chief Complaint Why are you seeing
Evolve180 / Ideal Northwest Health Profile
Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Email: Date of Birth: Age: Height: Occupation: How did you find out about our program? Marital
Phillips Brayford Orthopaedics 48 Tunnel Rd, Suite 203 Pottsville PA Phone: Fax: PATIENT INFORMATION
PATIENT INFORMATION Name: Date of Birth: Family Physician: Referring Physician: Height: Weight: Marital Status: Single Married Separated Widowed Divorced Employment Status: Employed Unemployed Disabled
Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one. Primary Address: Street # Street name Apt# City State Zip
Elissa S. Norton, MD 5162 Linton Blvd, Suite 203 P: (561) 877-3376 F: (877) 992-1153 info@brilliantdermatology.com Name: Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one Primary Address: Street # Street
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