medical history Questionnaire
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- Berniece Hubbard
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1 Surname: medical history Questionnaire Please take a few minutes to answer the following questions carefully as this assists us in preparing for your assessment. The information from this Questionaire may be used for research purposes. Your personal details will be withheld. Please tick what is correct. If you are not sure about the answer, leave it blank and ask the Doctor at your consultation. title: Mr / Mrs / Ms / Miss First Name: date of Birth: / / Phone No: (H) Address: (M) Pension/HCC No: Exp: / Medicare Number: Expiry date: / / ref No: Family Doctor Name: Address: Suburb: Phone: Postcode: How did you find out about us? Friend Doctor Referral Magazine Word of Mouth Internet
2 Your Current Complaint (Code YCC) 1. Are you consulting for: a. Varicose veins of the legs b. Spider veins of the leg c. Leg ulcers d. Recurrence of the veins after an operation e. Recurrence of the veins after injections f. Recurrence of the veins after Laser g. Pelvic congestions h. Varicose veins of the vagina i. Lymphatic problem of the legs j. Check-up k. Other:... (Code 1M) Your Symptons (Code YS) 2. Indicate which of the following problems you have experienced: a. Pain in your legs b. Heaviness in the legs c. Bursting pain in the calf after exercise d. Burning sensation in the calf e. Night cramps in the legs f. Itchiness in the legs g. Leg rash h. Swelling in the legs i. Tiredness in the legs j. Restlessness in the legs k. Other:... (Code 2L) 2
3 3. If you experience pain in your legs: (Code 3A) a. Does your pain get worse: No a. before your menstrual periods b. after extended periods of standing c. with heat d. at the end of the day e. following exercise and walking f. early mornings other: b. Does the pain get better by: (Code 3B) No a. rest b. elevating the legs c. elastic stockings d. medication:... e. exercise and walking f. when you stand up other:
4 Onset of Veins (Code OV) 4. When did your veins occur? a. Age:... b. Since childhood c. After taking the contraceptive pill d. Before pregnancy e. During pregnancy f. After pregnancy (while breast feeding). specify which pregnancy:... g. After menopause h. After an operation i. After trauma other: Ladies only: Do you suffer from: (Code 5PC) a. Heaviness in the lower abdomen... b. Pain in the lower abdomen... c. Burning sensation in the groin... d. Difficult and painful intercourse... e. Hemorrhoids... f. Frequent urination... g. Constipation... 4
5 Past Venous History (Code PVH) 6. Have you had any of the following: No a. Phlebitis (inflammation of a vein)... b. DVT (blood clot in a deep vein)... c. Pulmonary embolism (blood clotinthelung)... d. Ulcer of the legs... e. Bleeding disorder... f. Easing bruising... g. Required Warfarin or had injections in the tummy for any reason 7. Have you had previous treatments for your veins? No (Code 7Y 7N) if yes, with what method? a. injection b. operation c. laser d. other:... by whom and when? Did you have any problems afterwards? Were you happy with the overall results? 5
6 Past Medical History (Code PMH) 8. Do you have a history of: No a. HIV / AIDS... b. Hepatitis A, B, or C, please indicate... c. Blood transfusions... d. Asthma... e. Diabetes on Insulin, tablets, or diet controlled?... f. High blood pressure... g. Seizures, convulsions or epilepsy... h. Stroke... i. Bad circulation... j. Cancer... k. Arthritis or other types of autoimmune disease (e.g. Lupus)... l. Thyroid problems please explain... m. Heart disease... o. Migraine... p. Hole in the heart?... other medical problems
7 Gynaecological History (Ladies only) (Code GH9) 9. How many times have you been pregnant?... (include any termination or miscarriage) How many children do you have?...(code GH10) 11. Are you pregnant? (if applicable) 12. Are you planning a pregnancy soon? (if applicable) 13. Are you currently breast feeding? (if applicable) 14. Have you had a hysterectomy? (if applicable) if yes what year?... No 15. Are you taking the Pill? (if applicable) if yes which one?... for how long?... No 16. Hormone Replacement Therapy? (if applicable) if yes which one?... for how long?... No Surgical History 17. Please name all operations you have had with relevant year 7
8 Family History (Code FH) 18. Do you have a family history of: No a. Varicose vein problems... b. Spider veins... c. Phlebitis (inflammation of the vein)... d. Blood clots... e. Bleeding disorders... f. Leg ulcers... g. Other problems affecting the veins or circulation? Psychological History 19. Do you suffer from: No (Code PH) a. Anxiety... b. Panic attacks... c. Claustrophobia... d. Needle phobia... e. Other psychological or psychiatric disorder... Social History 20. About you:... a. single d. regular alcohol... / day b. married e. social drinker c. smoker... / day f. occupation
9 Medications 21. Regular Medications... Are you taking fish oil extract? No 22. Are you taking Iron Tablets? No (Code 24Y 24N) If yes for how long?... For what reason? Do you take aspirin or anti-inflammatory drugs? No (e.g. Voltaren, Naprosyn, etc) Allergies 24. Have you had any of the following allergic reactions? (Code A1Y A1N) No a. Eczema... b. Hives... c. Hay fever... d. Anaphylactic shock (severe life threatening allergic reaction) if yes please explain what happened... 9
10 25. Do you have an allergy to any of the following? If you answer to any of the following, please explain what happens if you take them No a. Foods... b. Local anaesthetic... c. Tapes... other What are your feelings towards surgery on your veins? a. Don t mind b. If really necessary c. Opposed 27. Are there any pending travel arrangements? No (if yes please give details) Have you had any problems with your legs with travel? No (if yes please explain)... 10
11 Thank you for your time! 11
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Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression
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
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:
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
New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:
New Patient Packet Patient Name: DOB: Age: Sex: Male / Female Height: Weight: PHYSICIAN CARE Primary Care Physician: Address: City: State: Zip: Phone: Fax: Referring Physician (if different from PCP):
Florida Orthopaedic Institute Urgent Care
Date: Florida Orthopaedic Institute Urgent Care Patient Questionnaire Initial Evaluation Patient Name: MR# (Office Use only): Family/Primary Doctor: Phone: Family/ Primary Doctor Address: Who referred
Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
Patient Information Camas Acupuncture & Nutrition General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth:
Other doctors to receive copies of records : Chief complaint / history of present illness (Describe why you have been referred here):
Patient Name: Date: Age: Date of Birth: Preferred Name: Preferred Language: Address: City: State: Zip: Phone: Cell Phone: Preferred Phone: Emergency Contact: Relationship: Email: If you would like to opt
Health History. Personal Health History. Institute of Complementary Medicine. FOC Health History - ICM
Reason for office visit today FOC Health History - ICM Health History Whom may we thank for referring you today? Do you have another primary care provider? Date of last physical exam Previous or referring
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
NEW PATIENT QUESTIONNAIRE
Page1 Mala Bathija MD, PLLC 44000 West 12 Mile Road, Suite 212 Novi, MI 48377 14500 Northline Road Southgate,MI 48195 NEW PATIENT QUESTIONNAIRE Last Name First Name Phone # DOB Age Sex: M F Referring Physician
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work)