New Patient Specialty Intake Form Department of Surgery

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1 This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient General Intake Form along with this form. The General Intake Form is available at this office or online through our interactive web site, MyChart. Name Date of birth Today s Date REASON FOR VISIT CARE TEAM Referring Physician Specialty Phone Primary Care Physician Phone Cardiologist Phone Other Involved Provider Specialty Phone MEDICATION INFORMATION Date Started Medication Dose(mg) Frequency Given for: New Patient Specialty Intake Form Department of Surgery Herbs, Over the Counter medications

2 PAIN ASSESSMENT Are you having any pain? Yes No How long you have had your pain? Where do you feel the pain?_ Is your pain is in one spot or spread out? How does the pain feel? Aching, Cramping, Gnawing, Heavy, Hot or burning, Sharp, Shooting, Splitting, Stabbing, Tender, Throbbing, Tiring or Exhausting, Other How severe it is? Use the pain scale below 0 Pain free. Mild Pain Nagging, annoying, but doesn't really interfere with daily living activities. 1 Pain is very mild, barely noticeable. Most of the time you don't think about it. 2 Minor pain. Annoying and may have occasional stronger twinges. 3 Pain is noticeable and distracting, however, you can get used to it and adapt. Moderate Pain Interferes significantly with daily living activities. 4 Moderate pain. If you are deeply involved in an activity, it can be ignored for a period of time, but is still distracting. 5 Moderately strong pain. It can't be ignored for more than a few minutes, but with effort you still can manage to work or participate in some social activities. 6 Moderately strong pain that interferes with normal daily activities. Difficulty concentrating. Severe Pain Disabling; unable to perform daily living activities. 7 Severe pain that dominates your senses and significantly limits your ability to perform normal daily activities or maintain social relationships. Interferes with sleep. 8 Intense pain. Physical activity is severely limited. Conversing requires great effort. 9 Excruciating pain. Unable to converse. Crying out and/or moaning uncontrollably. 10 Unspeakable pain. Bedridden and possibly delirious. Very few people will ever experience this level of pain. Is your pain constant or does it come and go? What activities make pain worse or improve it? Does your pain limit what you can do? How often does the pain occur and how long does it last? Does anything trigger the pain?

3 SURGICAL HISTORY Please use the space below to explain your past surgical procedures including dates. Cancer Surgery History Any difficulty with anesthesia? Chemotherapy History Radiation Treatment History SCREENING EXAMS Please list the most recent date and result of the following tests. Colonoscopy PSA and Prostate exam (men) Mammogram (women) Pap smear (women) Skin cancer screening exam OB/GYN HISTORY (for women only) How many pregnancies? Date of each delivery Date of last menstrual period

4 Current birth control Have you taken and estrogen or other female hormones in the last 10 years? SOCIAL HISTORY Marital status Children Yes No Ages and gender Occupation Education/highest grade completed Exercise Recreational drug use history Any IV drug use? Travel history REVIEW OF SYMPTOMS Please circle any of the following which have been a problem in the past month. General Fatigue Fever Sweats Pain Weight loss Weight gain Appetite change Activity change Skin Itching Rash Mole change Yellowing of skin Pallor Mass Cuts Changes in nails Hair changes Other changes Eyes Vision change Itching Discharge Cataracts Glaucoma Yellowing of eyes Ears, nose, mouth Dizziness Ringing in ears Hoarseness Sore throat Nose bleed Sinus infection Dental problems Mouth sores Change in taste Breasts Discharge Mass Pain Tenderness Lungs Cough Shortness of breath Chest pain with breathing Coughing blood Wheezing Heart Chest pain Irregular heartbeat Blood pressure problems Fainting episodes Ankle swelling Leg pains Need >1 pillow to sleep Gastro-Intestinal Abdominal pain Distention Nausea Vomiting Diarrhea Constipation Jaundice Black stools Blood in stools Clay-colored stools Floating stools Loose stools Difficulty swallowing Heart burn Hemorrhoids Rectal pain

5 Hepatitis A, B, or C infection REVIEW OF SYMPTOMS Continued Genitourinary Painful urination Frequent urination Urgent urination Blood in urine Kidney stones Urinating at night Flank pain Difficulty urinating Musculoskeletal Arthritis Stiffness Swelling Backache Cramps Muscle ache/pain Nervous system Headache Seizure Dizziness Tremors Memory loss Paralysis Numbness Tingling Loss of consciousness Endocrine Thirst change Heat or cold intolerance Mental health Anxiety Depression Personality change Agitation Suicidal thoughts Anger control problems Alcohol or drug problems Male reproductive Testicular pain Swelling Sexual difficulty Female reproductive Pelvic pain Loss of period Abnormal bleeding Sexual difficulty Hot flashes Vaginal dryness Hematologic and lymph system Anemia Bruising Bleeding Repeated infections Lymph node swelling Lymph node tenderness Finished! Thank you for choosing Baylor Department of Surgery. Please your completed forms to or you can fax it to prior to your appointment.

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