HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU**
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1 Name: Date: D.O.B: HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU** PAST MEDICAL HISTORY: Anxiety Arthritis Asthma A-Fib BPH Bone Marrow Transplant Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes If yes, AIC Sugar Who is your primary physician treating your diabetes? End Stage Renal Disease GERD / REFLUX Hearing Loss Hepatitis High Blood Pressure If yes, last blood pressure reading / HIV/AIDS High Cholesterol Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke Other Please list PAST SURGICAL HISTORY: Appendix Removed Bladder Removed Breast: Biopsy, Lumpectomy, Mastectomy Colon: Cancer, Diverticulitis, Colostomy Gallbladder Removed Heart: Valve replacement Heart: Coronary Artery Bypass Heart: PTCA Heart Transplant Joint Replacement, Knee Right / Left Joint Replacement, Hip Right / Left Kidney: Biopsy, Stone Remove, Transplant Liver: Shunt, Transplant, Hepatectomy Ovaries: Endometriosis, Cancer, Cyst, Tubal Pancreas: Pancreatectomy Prostate: Biopsy, Cancer, TURP Rectum: APR, Resection Skin Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed Testicles Removed Right / Left/ Both Hysterectomy: Fibroids, Cancer C- Section Valve Replacement OTHER- Please list PHARMACY: (location) 1
2 MEDICATIONS: If you have a medication list, we can make a copy for our records. EYE DROPS: Glaucoma drops: Artificial tear: Other: ALERTS: Do you have or have you ever had one of the following? Blood Thinners Artificial Heart Valve Defibrillator Pacemaker MRSA ALLERGIES: (circle all that apply) REACTION No Known Drug Allergy NKDA SEVERITY Sulfa MILD MODERATE- SEVERE Codeine MILD MODERATE- SEVERE Penicillin MILD MODERATE- SEVERE Adhesive MILD MODERATE- SEVERE Lidocaine MILD MODERATE- SEVERE OTHER: MILD MODERATE- SEVERE MILD MODERATE- SEVERE MILD MODERATE- SEVERE 2
3 SOCIAL HISTORY: Cigarette Smoking: Never smoked Former Smoker Current Smoker **CIRCLE ALL THAT APPLY** Alcohol Use: None Social (less than 1 a day) 1-2 Drinks a day 3 or more Drinks a day FAMILY HISTORY: PARENTS, GRANDPARENTS, SIBLINGS, AUNTS, UNCLES Glaucoma Macular degeneration Retinal detachment Diabetes Stroke Heart disease Cancer Thyroid Arthritis Other: REVIEW OF SYSTEMS: **CIRCLE ALL THAT APPLY** -----some may be the same as medical history----- EYES: ENDOCRINE: RESPIRATORY: CARDIOVASCULAR: CONSTITUTIONAL: NEUROLOGICAL: MUSCULOSKELETAL: PSYCHIATRIC: ENT/ MOUTH: GASTROINTESTINAL: GENITOURINARY: INTEFUMENTARY: HEMATOLOGIC: IMMUNOLOGIC: Change in vision, Pain, Tearing, Redness, Jaw Pain, Scalp Tenderness, Sudden vision loss Diabetes, Thyroid Shortness of breath, Congestion, Wheezing High Blood Pressure, Cough, Rapid Heart Beat Sudden Weight Loss, Fever, Chills Headaches, Seizure, Stroke, Paralysis Arthritis, Joint Pain, Stiffness Anxiety, Depression, Insomnia Stuffy nose, Earache, Dry mouth Upset stomach, Diarrhea, Constipation, Burning Urination, Urinary Frequency, Incontinence Rash, Changing Moles Anemia, Bleeding Hay fever, Hives 3
4 **CIRCLE ALL THAT APPLY** OCULAR HISTORY: Allergic Conjunctivitis Amblyopic (Lazy Eye) Blepharitis Cataract Right/ Left Contact Lens Corneal Dystrophy Right/ Left Diabetic Retinopathy (background) Right/ Left Diabetic Retinopathy (proliferative) Right/ Left Dry Eyes Glasses Glaucoma -- Right/ Left Macular Degeneration Right/ Left Macular ERM Right/ Left Narrow Angles Right/ Left Ocular Hypertension Right/ Left Ocular Migraine Foreign Body Removal Retinal Tear Right/ Left Strabismus PVD Right/ Left Vitreous Floaters Right/ Left Other: OCULAR SURGERY: Blepharoplasty Right/ Left Cataract Surgery Right/ Left Corneal Transplant Right /Left DSAEK Right/ Left Eye Muscle Surgery Intravitreal Injections Right/ Left LASIK Right/ Left LPI Right/ Left LTP Right / Left PRK Right/ Left Ptosis Repair Right/ Left Punctal Plugs Right/ Left Strabismus Surgery Retinal Laser Right / Left Trabeculectomy Right/ Left Tube Shunt Right/ Left YAG Capsulotomy Right/ Left Other: 4
5 GADDY EYE CLINIC PATIENT INFORMATION SHEET Last Name: Marital Status: First Name: Employer: Middle Initial: Suffix: Sex: Phone: Work Phone: Soc. Sec. # Race: Language: Date of Birth: Age: Ethnicity: (please circle) Hispanic / Non-Hispanic Street Address: City, State, Zip: INSURANCE INFORMATION: Primary Insurance: Policy Holder s Name: Policy Number: Policy Holder s SSN#: Policy Holder s DOB: Policy Holder s Employer: Secondary Insurance: Policy Holder s Name: Policy Number: Policy Holder s SSN#: Policy Holder s DOB: Policy Holder s Employer: In Case of Emergency: Phone: SIGNATURE ON FILE: I authorize payment benefits to be made payable to Dr. Gene Gaddy. My authorization is hereby given to Dr. Gene Gaddy to submit any claims to my insurance carrier in my behalf. I understand that I am responsible for deductible amount and the percent that my insurance does not cover. Policy Holder/Patient Date 5
Medical History Record
Medical History Record Today s For faster service, please complete the following form prior to arriving at our office. FIRST NAME: M.I. LAST NAME: Address City State Zip Code D.O.B. Sex: M F Email Home
Name DOB Date. Past Surgical History
Name DOB Date Past Medical History Anxiety Coronary Artery Disease Hypercholesterolemia Arthritis Depression Hyperthryroidism Asthma Diabetes Hypothyroidism Atrial Fibrillation(Irregular Heartbeat) End
Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone
Date Patient Last Name First Name Middle Name Gender (circle): Male Female Other: Marital Status (circle): Single Married Divorced Widowed Separated Home Address City State Zip Date of Birth Age Social
Preferred Pharmacy. Past Medical History
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Phone Number (day): Phone Number (evening): Email Address: Emergency Contact: Preferred Pharmacy Name: Phone Number: City and
NAME DATE Page 1. Other. Kidney Removed (Right, Left) Bladder Removed. Ovaries Removed for Endometriosis Breast Biopsy
NAME DATE Page 1 Past Medical History: (please circle ALL that apply) Anxiety Hepatitis Arthritis Hypertension Artificial joints HIV/AIDS Asthma Hypercholesterolemia Atrial fibrillation Hyperthyroidism
Intake and History Form
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Soc. Sec. #: Phone Number (day): Phone Number (day): Email Address: Emergency Contact: # Preferred Language: _ Race: Ethnic Group:
Patient Registration Form
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PATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
PATIENT INFORMATION Name: First Name MI Last Name Date of Birth: / / Sex: Male / Female / Declined SSN: Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Declined Marital Status: Single Married Divorced/Separated
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Past Medical History: (please mark the medical conditions that you currently have) Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH Breast Cancer Colon Cancer COPD Coronary Artery
F M S M W D. Age Birth Date Gender Marital Status Cell Phone
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TO SERVE YOU MORE EFFICIENTLY, PLEASE COMPLETE THIS FORM AND RETURN IT TO THE FRONT DESK BEFORE YOU ARE CALLED TO AN EXAM ROOM. THANK YOU.
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Date: PATIENT INFORMATION Name SS# LAST FIRST MIDDLE INITIAL. Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed
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Patient or Parent/ Guardian Signature Date
Today s Date Appointment Date Last Name First Name Middle Initial Birthdate Age Title: (circle one) Mr. Mrs. Dr. Ms. Miss Sex: (circle one) M F Home Phone Cell Work Email Primary Insurance ID number Subscriber
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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
Vanguard Rheumatology Partners REGISTRATION FORM (Please Print)
REGISTRATION FORM (Please Print) Today s Date: Primary care doctor: Referring doctor: PATIENT INFORMATION Patient s last name: First: Middle: Sex Age: Marital status: Single Married M F Part Sep Div Widow
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 These questions are general screening questions designed to identify areas where additional attention may be required. Please bring
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: Address: Relationship: Address:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: ( ) Marital Status: Married Single Divorced Widowed Cell Phone: (
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E mail newsletters, reminders, statements, etc. Emergency Name: Phone: City: State: Zip: Home