PATIENT DEMOGRAPHIC INFORMATION
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- Dwayne Byron Casey
- 5 years ago
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1 PATIENT HISTORY FORM Date of Visit: Steven E. Levine, MD PATIENT DEMOGRAPHIC INFORMATION Name: Last First Middle Initial Home Address City / State Zip ( ) ( ) Home Phone Cell Phone Address Date of Birth: / / Social Security Number: - - Marital Status: Single Married Divorced Widowed Primary Care Physician: Phone: ( ) EMERGENCY CONTACT INFORMATION Contact Person: Phone: ( ) Relationship: May we release your Personal Health Information to this person? Yes No REFERRAL INFORMATION How were you referred to our office? Primary Care Physician Patient Internet Phone Book Advertisement Other Provider Name: Phone: ( ) CONDITION INFORMATION Chief Complaint: When did you start experiencing these symptoms?
2 PREVIOUS DIAGNOSTIC TESTING What types of diagnostic testing have you had for this condition? Type of Test: Date of Test: Location of test: No Previous Testing MRI C/T Scan X-rays EMG Pet Scan PERSONAL MEDICAL HISTORY Are you being treated for or been diagnosed with had any of the following medical conditions? (Check applicable boxes below) EENT Gastrointestinal Neurological Cancer Cirrhosis Gallstones GERD Hernia IBS Pancreatitis Ulcers Blindness Cataracts Contacts Deaf Glaucoma Hearing Aids Hearing Loss Nose Bleeds Season Allergies Sinusitis Swallowing Problems Cardiovascular Angina / CAD Arrhythmia Atrial Fibrillation Blood Vessel Blockage Congestive Heart Failure DVT Heart Murmur Hypotension (Low Blood Pressure) Hypertension (High Blood pressure) Pacemaker Peripheral Vascular Disease Rheumatic Fever Stent Valve Replacement Surgery Other Genitourinary Hysterectomy Kidney Stones Renal Failure Renal Insufficiency Sexual Dysfunction Tubal Ligation Endocrine Diabetes Hyperthyroid Hypothyroid Menstrual Irregularity Obesity Thyroid Disorder Hematologic Anemia Bleeding Disorder Transmissible TB Recent TB Exposure TB Test Alzheimer s Aneurysm Epilepsy / Seizures Headaches Head Injury Migraines Multiple Sclerosis Parkinson s Disease Peripheral Neuropathy Stroke Psychological ADD / ADHD Anxiety Bi-polar Disorder Dementia Depression Schizophrenia Respiratory Asthma COPD Diabetes: Type 1 or Type 2 Emphysema Sleep Apnea Bone Cancer Breast Cancer Colon Cancer Lung Cancer Melanoma Prostate Cancer Other: Musculoskeletal Back Pain Broken Bones Connective Tissue Disorder Decrease in Muscle Size Fibromyalgia Kyphoscoliosis Muscular Disorder Neck Pain Osteoarthritis Rheumatoid Arthritis Scoliosis Disease Hepatitis A Hepatitis B Hepatitis C HIV AIDS Shingles 2 P a g e
3 SURGICAL HISTORY Please check any box listed below pertaining to your surgical history: No Surgical Procedures General Surgery Gynecology Orthopedic Appendectomy Cholecystectomy Gastric Bypass Hernia Surgery AICD CABG Heart Procedure Cardiac Catheterization Coronary Stents Heart Valve Replacement Permanent Pacemaker Angioplasty Ablation C-Section Hysterectomy Tubal Ligation Other Surgeries Cataract Surgery Kidney Transplant Other 1: Other 2: : Other 3: : Other 4: : Knee Replacement (Year: ) (Circle one) Right Left Both Hip Replacement (Year: ) (Circle one) Right Left Both Carpel Tunnel Surgery (Year: ) (Circle one) Right Left Both Thoracic Laminectomy Cervical Laminectomy Lumbar Laminectomy Thoracic Spine Fusion Spine Levels: Cervical Spine Fusion Spine Levels: Lumbar Spine Fusion Spine Levels Shoulder Surgery (Circle one) Right Left Both PRIOR TREATMENTS Please check any box listed below pertaining to your previous treatment history: Type of Treatment Helpful Not Helpful Dates of Treatment Physical Therapy Traction Unit Chiropractic Back Brace TENS Unit Muscle Stimulator Epidural Steroid Injection Facet Joint Injection / Medial Branch Block Radiofrequency Ablation Trigger Point Injections Sacroiliac Joint Injections Nerve Blocks Spinal Cord Stimulator Intrathecal Pump Kadian 3 P a g e
4 PRIOR MEDICATIONS Please check the applicable boxes listed below, pertaining to any medications you may have taken in the PAST (This section does not pertain to medications you are currently taking) Medication Type / Name Helpful Not Helpful Steroids Steroids (Oral) Steroids (Intramuscular-Injected) NSAID s Acetaminophen (Tylenol) Aspirin Celecoxib (Celebrex) Diclofenac (Voltaren-Oral) Flector Patch Ibuprofen (Advil, Motrin) Lodine Meloxicam (Mobic) Nabumetone (Relafen) Naproxen (Aleve) Zipsor Muscle Relaxants Baclofen Carisoprodol (Soma) Cyclobenzaprine (Flexeril) Diazepam (Valium) Metaxalone (Skelaxin) Methocarbamol (Robaxin) Tizanidine (Zanaflex) Short Acting Opioids Acetaminophen/Oxycodone (Percocet, Roxicet) Codeine/ Acetaminophen (Tylenol 3) Fentanyl (Actiq, Sublimaze, Subsys, Fentora) Hydrocodone (Lortab, Norco) Hydromorphone (Dilaudid) Morphine (MSIR) Oxycodone (Percocet, Roxicet, Roxicodone) Tramadol (Ultram) Tapentadol (Nucynta) Long Acting Opioids Avinza Buprenorphine (Butrans, Suboxone) Buprenorphine Patch Embeda Fentanyl Patch (Duragesic) Hydromorphone (Exalgo) Side Effects (If any) 4 P a g e
5 PRIOR MEDICATIONS (Continued) Please check the applicable boxes listed below, pertaining to any medications you may have taken in the PAST (This section does not pertain to medications you are currently taking) Medication Type / Name Helpful Not Helpful Long Acting Opioids Cont d Methadone (Symoron, Dolophine) Morphine (MS Contin) Oxycontin Oxymorphone (Opana) Anti-Neuropathic Agents Duloxetine (Cymbalta, Ariclaim) Gabapentin-IR (Neurontin) Gabapentin-Flow Release (Gralise) Milnacipran HCI (Savella, Dalcipran) Pregabalin (Lyrica) Topiramate (Topamax) Anti-Depressants Amitriptyline (Elavil) Bupropion (Wellbutrin) Citalopram (Celexa) Duloxetine (Cymbalta) Escitalopram (Lexapro) Fluoxetine (Prozac) Milnacipran (Savella) Nortryptyline (Aventyl, Pamelor) Paroxetine (Paxil) Sertraline (Zoloft) Trazadone (Desyrel) Venlafaxine (Effexor) Sleep Agents Ambien Lunesta Compound Medications Baclofen BioFreeze Bupivacane Capsaicin (Capsaicin Cream, Qutenza) Cyclobenzaprine Diclofenac Gabapentin Ketamine Ketoroiac Lidocaine Pain Cream Side Effects (If applicable): 5 P a g e
6 SOCIAL HISTORY Please check the applicable boxes listed below pertaining to your social history: Tobacco Use Occupation Sleep Habits Current every day smoker Current some day smoker Former smoker Never Smoker Date/Year Quit: # Packs smoked per day: # Years of Habit: Retired Disabled Unemployed Self-Employed Employed (Part-time) Employed (Full-time) Student Homemaker Poor Fair Good Stress Level Low Medium High Alcohol Use Ability to Care for Self Exercise Habits None Rarely Socially Daily History of Alcohol Abuse Yes, I m able to care for myself No, I m unable to care for myself Details: Never Rarely Frequently Daily Drug Use Diet Denies All Current User Past User Poor Amphetamines Fair Good Marijuana Cocaine Heroin Other: 6 P a g e
7 FAMILY HISTORY Please check any box listed below pertaining to your immediate family s medical history: Father Mother Brother(s) Sister(s) Unkown Unkown Unkown Unkown Arthritis Arthritis Arthritis Arthritis Asthma Asthma Asthma Asthma Back / Neck Pain Back / Neck Pain Back / Neck Pain Back / Neck Pain Bleeding Disorder Bleeding Disorder Bleeding Disorder Bleeding Disorder Cancer Cancer Cancer Cancer COPD COPD COPD COPD Heart Disease Heart Disease Heart Disease Heart Disease Connective Tissue Disease Connective Tissue Disease Connective Tissue Disease Connective Tissue Disease Diabetes Diabetes Diabetes Diabetes Sinusitis Sinusitis Sinusitis Sinusitis Epilepsy Epilepsy Epilepsy Epilepsy Hypertension Hypertension Hypertension Hypertension IBS IBS IBS IBS Kidney Disease Kidney Disease Kidney Disease Kidney Disease Mental Illness Mental Illness Mental Illness Mental Illness Muscular Disorder Muscular Disorder Muscular Disorder Muscular Disorder Lung Disease Lung Disease Lung Disease Lung Disease Osteoporosis Osteoporosis Osteoporosis Osteoporosis Stroke Stroke Stroke Stroke Tuberculosis (TB) Tuberculosis (TB) Tuberculosis (TB) Tuberculosis (TB) Thyroid Disorder Thyroid Disorder Thyroid Disorder Thyroid Disorder ALLERGIES List any allergies below, including your reactions (Ex: Shortness of breath, hives, itching, etc.): Allergic to: No Known Drug Allergies Reaction Type: 7 P a g e
8 CURRENT MEDICATION LIST List all medication(s) you are currently taking, including the strength, dose and frequency. If you take any of the following vitamins: Omega 3 (Fish Oil), Vitamin E, Vitamin D, please include them on the list below. Medication Name Strength Quantity / Dose Frequency Taken 8 P a g e
9 PAIN DIAGRAM On the diagram below shade the area where you are currently experiencing pain that our provider is treating you for: Please circle the number below that best rates your current pain level no little moderate quite severe unbearable pain bad pain 9 P a g e
10 REVIEW OF SYSTEMS Please review the symptoms below and check any Yes boxes that apply to you now: I have not experienced any of the symptoms listed below. General Yes Gastrointestinal Yes Weight Loss Abdominal Pain Weight Gain Blood in Stool Fever Vomiting Fatigue Diarrhea HEENT Yes Urinary Yes Blurred Vision Frequency Discharge Hesitancy Ear Ringing Flank Pain Hoarseness Painful Urination Light Sensitivity Blood in Urine Nose Bleeds Pain Neurologic Yes Sore Throat Headache Confusion Respiratory Yes Numbness Wheezing Slurred Speech Cough Weakness Shortness of Breath Endocrine Yes Cardiovascular Yes Excess Sweat Chest Pain Excess Thirst Fainting Excess Hot Feet Swelling Excess Cold Palpitations Blood/Lymphatic Yes Skin/Breast Yes Bleeding Tendencies Rash Lymph Node Swelling Itching Easy Bruising Soreness Abscess Psychological Yes Anxiety Musculoskeletal Yes Depression Joint Swelling Severe Stress Joint Redness Panic Attacks Joint Pain Muscle Pain/Soreness Gait Problems Patient Signature Date: / / 10 P a g e
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Chayapathy Jollu, MD Board Certified in Physical Medicine and Rehabilitation Patient Initial Pain Questionnaire
Patient Initial Pain Questionnaire Date: Last Name: First Name: Middle Name: Age: Gender: M F Right handed Left handed Referring Physician: Primary Care Physician: Address: Address: Phone: Phone: Fax:
UnityPoint Clinic - Cardiology
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Health History Intake Form;
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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
Center for Pain Management New Patient Intake Form
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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
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
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Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
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
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Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
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Patient Interview Form
Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
Using the symbols below, please draw in the location of your symptoms on the diagrams. X = Pain 0 = Numbness / = Aching * = Pins & Needles
Date: DOB: Age: Gender: Right handed: Left handed: Who referred you? Is your problem related to : Job injury Date: Car accident Date: Date: Briefly describe your main problem/complaint. Also, describe
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
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