Other physician #1. #(p) List any allergies to medications. Please list below all other current medical conditions or previous surgeries
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- Priscilla Peters
- 5 years ago
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1 Dept. of Obstetrics and Gynecology Division of Gynecological Pain and Minimally Invasive Surgery Frank Tu, MD, MPH Sangeeta Senapati, MD, MS Howard Topel, MD Name: New Patient Intake Questionnaire Names & Phone # s for physicians involved in your care Referring Physician Other physician #1 #(p) #(p) #(f) #(f) In brief, what is the main reason you are seeing the doctor today: What was the first day of your last menstrual period: How many pregnancies have you had How many living children do you presently have List any allergies to medications Please list below all other current medical conditions or previous surgeries Medical Conditions List all medical conditions Surgeries (Date, Surgeon) Do you have the any of the following? Fibromyalgia Yes No Chronic Fatigue Syndrome Yes No Interstitial Cystitis Yes No Irritable Bowel Syndrome Yes No Low Back Pain Yes No Chronic Headaches Yes No TMJ (temporomandibular Yes No joint disorder)
2 MEDICATIONS - current FAMILY HISTORY Please indicate if any members have the following: (and list who they are ex. maternal grandmother) Breast cancer Colon cancer Ovarian cancer Easy bleeding problems Blood clotting issues REVIEW OF SYSTEMS: Please mark any symptoms that you have experienced in the last 3 months. check this box if you do NOT have any of these symptoms General = yes Chronic fatigue Fevers Difficulty falling or staying asleep Unintentional weight loss Unintentional weight gain Skin Rash Itching Vaginal / vulvar ulcers or fissures Head and Neck Itchy eyes Sore throat Mouth sores or ulcers Bleeding gums Heart Chest pain Irregular heart beat Ankle/foot swelling Lungs Shortness of breath Chronic cough Wheezing Endocrine Excess hair growth Nipple discharge Hot flashes Gastrointestinal = yes Nausea or vomiting Poor appetite Abdominal bloating/fullness Heartburn Constipation Diarrhea Blood in stools Pain with bowel movements Urinary Frequent urination (>8 times/day) Urgency (sudden urge to urinate) Urine leaking Pain with urination Blood in urine Incomplete bladder emptying Night time urination (>2 /night) Musculoskeletal Muscle or joint pain Body aches or stiffness Leg pain Back pain Neurologic Headaches Dizziness Memory Loss Low attention
3 Some women experience pain during the following times or with certain activities. Please rate the severity of pain that you experience during these times by marking ONE box for each activity. Please answer all questions 0 indicates no pain at all, 10 indicates pain as bad as you can imagine. 0=no pain 10=pain as bad as you can imagine Pain with urination Pain with full bladder Pain with bowel movements Deep pain with intercourse Pain with entry during intercourse Pain with tampon insertion Go to the next page only if you are seeing the doctor for pelvic pain issues
4 PRIOR TREATMENTS for Pelvic Pain symptoms: Please mark ALL treatments that you have ever used FOR YOUR PELVIC PAIN, o LIST THE SPECIFIC MEDICATION UNDER HORMONAL THERAPY, ANTI-SEIZURE MEDICATION, ANTIDEPRESSANT MEDICATION, AND OPIOID MEDICATION Please mark the NO box if you have never used the listed treatment for pelvic pain. For each treatment that you have used, please indicate how long you used this medication for (in months) For each treatment that you have used, please indicate whether you are still using this medication for pelvic pain, and how helpful each treatment was (or has been) for your pelvic pain. TREATMENT Hormonal therapy: YES NO Total duration of use (months) CHECK BOX IF You are STILL USING THIS TREATMENT NOT at all I have not used hormonal therapy HOW HELPFUL was this treatment? Check one box c. Anti-seizure medications A little bit Somewhat I have not used anti-seizure medications for my pain Antidepressant medications A great deal I have not used antidepressant medications for my pain Opioid medications (ex: Vicodin, Percocet, Lortab, Oxycontin) I have not used opioid medications a. b. Any over-the-counter pain medicines (ex: Ibuprofen, Aleve, Tylenol) Mirena IUD Other medication: Physical therapy Acupuncture Nerve blocks or injections EXAMPLES OF MEDICATIONS (these are just examples, you may have been on other medications): HORMONAL THERAPIES: ANT-SEIZURE MEDICATIONS ANTI-DEPRESSANTS Oral contraceptive pills Anastrazole (Arimidex) Gabapentin (Neurontin) Amitriptyline (Elavil) Paroxetine (Paxil) contraceptive patch Letrozole (Femara) Pregabalin (Lyrica) Nortriptyline (Pamelor) Citalopram (Celexa) contraceptive vaginal ring Danazol Tigabine (Gabitril) Desipramine (Norpramin) Sertraline (Zoloft) DepoProvera Oral progestin: provera, prometrium Topiramate (Topamax) Imipramine (Tofranil) Venlafaxine (Effexor) DepoLupron, Zoladex, Synare Norethindrone (aygestin) Lamotrigine (Lamictal) Fluoxetine (Prozac) Duloxetine (Cymbalta) A very great deal
5
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Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX 75460 Phone (903) 905-4609 Fax (903) 905-4611 Enclosed are forms for you to complete prior to your appointment. Please bring these completed
Gender: M F Race: Caucasian African American Hispanic Other
Weight Loss Surgery Patient Information First Name: Middle Initial: Last: Date of Birth: Age: Social Security #: Gender: M F Race: Caucasian African American Hispanic Other Address: City: State: Zip: Home
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
New Patient Information
Kairos Acupuncture, Chinese Herbs, & Bodywork LLC 262-323-9022 kairosacupuncture@hotmail.com acupuncturewestbend.com New Patient Information Name Today s Date Street Address Apt. City State Zip Preferred
MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM
MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM Name: Date Reason for Consultation: Physicians involved in your care: Best Contact Phone #: Can we leave a message: YES NO
Emotional Relationships Social Life Sexually Recreation
Name Date Address City State Zip Married Single Partner Divorced Widowed Date of Birth SS# Email Work Phone Home Phone Cell Phone Occupation Referred by Emergency Contact Family Physician Contact May we
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury