Piedmont Healthcare Endocrinology
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1 Amy E. McLaurin, MD, CDE, FACE Harry Demetri, DO Theresa Faires, FNP-C, CDE Todd Kennedy, PA-C Elizabeth Rodden, RN, BSN, CDE Lisa Meade, PharmD-CDE Piedmont Healthcare Endocrinology 142 Sherlock Drive, Statesville, NC (Next to Davis Regional Medical Center- last building) P: F: We welcome you to our office! As a new patient to the Endocrinology office, we ask that you arrive 15 minutes before your scheduled time, with the most current/ updated insurance card(s) and your office visit copayment. We have included New Patient Paperwork that will need to be filled out prior to arrival. This will allow our team to better serve you with an efficient check in process. If you have any questions, please do not hesitate to call. Appointment Information: Name: Date: Time: With: Dr. McLaurin Dr. Demetri Theresa Faires, NP Todd Kennedy, PA *If you are unable to keep your appointment, kindly give 24 hours notice by calling our office. If you do not show for your appointment, you will not be rescheduled.
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3 Amy E. McLaurin, MD, CDE, FACE Harry Demetri, DO Theresa Faires, FNP-C, CDE Todd Kennedy, PA-C Elizabeth Rodden, RN, BSN, CDE Lisa Meade, PharmD-CDE Date MRN: NEW PATIENT INFORMATION Patient Name: Address: Length of time to travel to this office: Phone # Sex Date of Birth Marital Status You Live with: # Of Children and their ages: Are you able to read and write at this time? Yes No Occupation and place of work: (Or disability due to): Pharmacy/ Mail Order: Family Doctor: Other Doctors: Person who referred you to this office and their relationship to you: What is your reason for coming to our office today? How long have you had the above mentioned problem that you are visiting us for today? What treatments have you tried for this problem? What has improved your problem? Are you currently on an exercise regimen? (please circle one) and if so the length of time? How often do you engage in this physical activity and if you re currently not exercising please explain why below: Do you follow a specific meal plan? Yes No Do you eat three meals a day? Yes No Number of calories or type of meal plan Do you eat the same time daily? Yes No Meal you skip/eat at various times is:
4 Who usually cooks your meals? Do you snack between meals? Often Occasionally Rarely Never Do you use Tobacco? Yes No General Medical History: Medication allergy and reaction when used: Medical problems: High Blood Pressure High Cholesterol Heart Disease Kidney Disease Thyroid Disease Stroke or Mini Stroke Arthritis Allergies Osteoporosis OTHER: Surgeries/Hospitalizations and approximate dates: FAMILY HISTORY: Mother is: Living Deceased Age at death and cause: Father is: Living Deceased. Age at death and cause: # of Brothers # of Sisters # of children you have and health LIST WHICH RELATIVES HAVE OR HAVE HAD ANY OF THE FOLLOWING ILLNESSES: Skin Disease Rheumatoid Arthritis Back Problems Osteoporosis Childhood Onset Diabetes Adult onset of Diabetes High Cholesterol Thyroid Disease High Blood Pressure Heart Disease Stroke _ Obesity Cancer OTHER FAMILY ILLNESSES: (Females ONLY)
5 # Of times Pregnant # of Miscarriages Age Menstrual cycle began Length of average cycle Are your cycles regular? Yes No Year/Age of last cycle List of any previous use of Hormone Therapy: Are you considering becoming pregnant? Yes No Current method of birth control New Patient Medications & Review of Systems Patient Name: Please list your medications, dosage, and time of day used. (Please bring medications with you in a sealed container if unable to complete this section of the form.) Medication Allergies: Medication name Mg/cc or dose Times of day taken Medication name Mg/cc or dose Times of day taken Directions: Circle Y for Yes if you are currently having the problem or N for No if you are not. Date: Examiner s Notes Chest pains/pressure Less Concentration Date: Examiner s Notes Heart Palpitations Vision changes Joint Pain Dry Eyes Difficulty Breathing Difficulty Swallowing Cough Poor Appetite Swelling Nausea/Vomiting Fatigue Weight Gain/Loss Tingling/Numbness Diarrhea
6 Headaches Constipation Bloating Excessive Thirst Muscle weakness Frequent urination Dry skin Night time urination Hair loss Nervousness Change in cycle Brittle Nails Sweating/hot flashes Not sleeping well Sadness/Crying Social History Changes in diet/ meals #Times/week exercising # of Alcoholic drinks per day # of Cigarettes smoke daily Street Drug use Change Jobs Change in address Family health Changes Change in Marital status Change in who you live with Hospital stay or visit to the Emergency room Insurance pays on your Diabetes test strips Examiners Initials:
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FAMILY MEDICINE New Patient Medical History Form
FAMILY MEDICINE New Patient Medical History Form Personal History : Name: Date of Birth / / (mm/dd/yyyy) Age Occupation Birthplace (City&Country) Marital Status (check one): Single Married Divorced Separated
Patient Label (Office Use)
Name: Patient Label (Office Use) VVMC Diversified Services Health History Survey And Contact Information Please provide the following information so we may contact you as needed. We may contact you to
Cell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
Patient: First Name Middle Initial Last Name. Date of Birth SSN. Address . City State Zip Code. Home Phone ( ) Cell Phone ( )
PATIENT DEMOGRAPHICS PATIENT INFORMATION Patient: First Name Middle Initial Last Name Date of Birth SSN Gender: Male Female Address Email City State Zip Code Home Phone ( ) Cell Phone ( ) Occupation Employer