New Patient Information Form
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- Baldric Bond
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1 Urogynecology New Patient Information Form NAME: UROGYNECOLOGY: NEW PATIENT INFORMATION FORM Why are you coming for this evaluation? How long have you had this problem? Has it been getting worse? yes no What treatments have you tried? _ MEDICATIONS & SUPPLEMENTS: Please list all medications you are currently taking (including any over- the- counter medications, vitamins, or herbal supplements/home remedies). Include dosage and how often you take it. If you need more room, please list all medications on a separate sheet of paper and attach it to this packet. Medication Name Dosage How Often Preferred Pharmacy: Phone: Address/Location: _ ALLERGIES/MEDICATION REACTIONS: Are you allergic to latex? no yes: if yes, please list reaction: Please list all medication allergies or reactions below, including the type of reaction experienced. If you need more room please list all medications & reactions on a separate sheet and attach it to this packet. Medication Name Type of Reaction (hives/rash, itching, shortness of breath, nausea, etc.)
2 Urogynecology Page 2 MEDICAL HISTORY: Number of: Pregnancies Vaginal Deliveries C- Sections HEME RESP Medical Problems Asthma Chronic cough Chronic Obstructive Pulmonary Disease (COPD) Blood clot in leg or arm Blood clot in lung Blood disorder- circle specific problem chronic anemia, von Willebrand's disease, sickle cell trait/disease, thalasemia, hemophilia Please check one: Current problem Past Problem Never a problem Heart Disease- circle specific problem heart attack, coronary artery disease, angina, congestive heart failure, stent placement ENDO CARDIAC Heart Condition- circle specific problem abnormal beats or rhythm, murmur, pacemaker, artificial valves High Blood Pressure Stroke Transient Ischemic Attack (TIA) Diabetes - circle specific treatment diet- controlled, oral medications, insulin shots Thyroid Disease- circle one: hypo- or hyper- NEURO MSK GI GU Kidney Disease- circle specific problem polycystic kidneys, renal insufficiency, renal failure (on dialysis), anatomic abnormalityof kidneys or ureters Kidney Stones Recurrent Bladder Infections (UTI)- > 3/year Interstitial Cystitis Abnormal Pap Smear- year: Irritable Bowel Syndrome- circle type diarrhea- predominant, constipation- predominant, mixed Chronic constipation Acid Reflux/chronic heartburn Liver disease- type: Arthritis- circle type osteo-, rheumatoid, psoriatic Fibromyalgia Epilepsy/Seizure Disorder Parkinson's Disease Multiple Sclerosis
3 Urogynecology Page 3 PSYCH OTHER Medical problems, continued Current Past Never Depression Anxiety Cognitive Impairment or Dementia Glaucoma- circle type: wide/open or narrow/closed Chronic Pain- Location: Cancer- circle type breast, cervical, endometrial/uterine, ovarian, bladder, kidney, other: Other: Other: SURGICAL HISTORY: Please list all past surgeries. I f you need more room, please list all surgeries on a separate sheet and attach to this packet. Hysterectomy? no yes: year Route- abdominal incision laparoscopic vaginal Removal of ovaries? no yes: both right left Year Type of Surgery Surgeon/Hospital Complications SOCIAL HISTORY: Do you No Past Use Yes Use tobacco? Use recreational drugs? Drink alcohol? # packs per day: # years of use: Type: How often? Type: # drinks per week:
4 Urogynecology Page 4 Occupation: retired disabled Are you currently sexually active? no yes Have you been sexually abused? no yes: as a child as an adult currently Have you been physically abused? no yes: as a child as an adult currently Are you a primary caregiver to someone? no yes: relationship: Marital/Relationship status married single divorced separated other: Who do you live with? alone spouse/significant other family other: What is your usual level of physical activity? very active & exercise regularly active a little active not active What is your current mobility level? walk without any problems or assistive devices need a cane or walker need help getting on an exam table use a wheelchair FAMILY HISTORY: check here if you are adopted and do not have this information Has anyone in your family (blood relative) been diagnosed with any of the following? Medical Problem Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Father Mother Brother Sister Other Bleeding or clotting problem (von Willebrands, hemophilia, platelet disorder, Factor V Leiden) Breast Cancer Colon or Rectal Cancer Diabetes Endometrial or Uterine Cancer Heart Attack Heart Disease Ovarian Cancer Stroke or TIA Other: Other:
5 Urogynecology Page 5 REVIEW OF SYSTEMS: Circle any of the following symptoms you are currently experiencing: Constitutional Skin HENT Eyes Cardiovascular Respiratory GI MSK Endo/Heme/Imm Neuro Psych fever chills weight loss weight gain malaise/fatigue sweating night sweats weakness rash itching headaches hearing loss ringing in ears ear pain ear discharge nosebleeds congestion sore throat blurry vision double vision pain with light in eyes eye pain eye discharge eye redness chest pain palpitations shortness of breath with lying down leg pain with walking leg swelling waking up at night short of breath cough coughing up blood productive cough shortness of breath wheezing heartburn nausea/vomiting abdominal pain diarrhea constipation blood in stool dark, tarry stools bloating muscle pain/aches neck pain back pain joint pain frequent falls easy bruising/bleeding allergies feeling too thirsty dizziness tingling/numbness tremor change in sensation change in speech weakness in one arm or leg seizures passing out/fainting depression suicidal ideas substance abuse hallucinations anxiety insomnia memory loss UROGYNECOLOGY: Were you treated for 3 or more bladder infections in the last year? no yes Do you have difficulty emptying your bladder? no yes Do you have pain when you urinate? no yes How many times do you get up to empty your bladder at night? 0 /rarely or more How often do you have bowel movements? daily every other day 1-2 times a week less than once per week Do you leak stool? no yes: liquid stool loose stool soft stool formed stool If you experience URINARY INCONTINENCE: Do you Usually have an urge to urinate before you leak urine? no yes Leak urine or rush to the bathroom when you see/feel/hear running water? no yes Leak urine or rush to the bathroom when you approach your home after being out? no yes Leak urine when you cough, sneeze, laugh, or exercise? no yes Wet the bed when you are completely asleep? no yes Feel like you leak urine constantly? no yes Wear pads to protect your clothing from leakage of urine? no yes If you do wear pads: What kind? pantiliner thin pad thick pad diaper
CENTER FOR ADULT PELVIC HEALTH & CONTINENCE CARE
CENTER FOR ADULT PELVIC HEALTH & CONTINENCE CARE 500 Red Creek Drive - Building 500 - Suite 120 Rochester, New York 14623 Telephone (585)487-3400 Fax (585) 334-3327 Website: Pelvichealth.urmc.edu Dear
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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
Providence Medical Group
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Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
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DATE OF BIRTH: MELANOMA INTAKE
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City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
UROGYNECOLOGY MEDICAL HISTORY QUESTIONNAIRE
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
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UROGYNECOLOGY. In your own words, please write the nature of your medical problem for which you are being seen today.
Thank you for taking the time to fill out this questionnaire. A detailed and accurate health history will enable us to give you the best care and treatment. NAME AGE DATE In your own words, please write
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)
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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
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Medication Allergies
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Psychiatric Evaluation Intake Form
Patient Contact Information Psychiatric Evaluation Intake Form Patient Name: Date of Birth: Age: Last First MI Address: Contact phone number: Email address: Emergency Contact/Number/Relationship: Primary
City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: Emergency Contact: Relationship: Phone
Patient Name: DOB: SS #: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Email Address: Emergency Contact: Relationship: Phone Referring Physician: Primary Physician: Other Physicians
Mary South, MD 3647 Medina Road Medina, OH Phone: Fax: has an appointment. on at AM/PM.
Mary South, MD 3647 Medina Road Medina, OH 44256 Phone: 234-205-2040 Fax: 234-205-2040 has an appointment on at AM/PM. To make sure your first visit goes smoothly, we ask that you complete the enclosed
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
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
Dear Mercy Cancer Center Radiation Oncology Patient
Dear Mercy Cancer Center Radiation Oncology Patient Welcome to our Department. In order to complete our records, and enable our physicians to ensure that your questions are fully addressed, we appreciate
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