Question 1: Has your doctor or health care professional told you that you had type 1 or type 2 diabetes?
|
|
|
- Gervase Cox
- 5 years ago
- Views:
Transcription
1 DIABETES - Questions list Question 1: Has your doctor or health care professional told you that you had type 1 or type 2 diabetes? Type 1 diabetes Type 2 diabetes Neither Routing rule: ( Type 1 Diabetes->2 Type 2 Diabetes->2 Neither->19 I do not know->19 ) Question 2: At what age was this diagnosed? Question 3: Are you taking medicine for this? and I do not take medication Routing rule: ( ->4 ->5 and ->4 I do not take medication- >19 ->19 ) Question 4: Was insulin your first diabetes medicine? Diabetes V1.2 Page 1 of 7
2 Yes No Question 5: At what age was this first treated? Question 6: Has your doctor or health care professional told you that you had type 1 or type 2 diabetes? Type 1 diabetes Type 2 diabetes Neither Routing rule: ( Type 1 Diabetes->9 Type 2 Diabetes->13 Neither->7 I do not know->19 ) Question 7: Have you ever had gestational diabetes (ONLY during pregnancy)? Yes, I have been pregnant and have had gestational diabetes I have been pregnant but I have never had gestational diabetes I have never been pregnant Routing rule: ( Yes, I have been pregnant and have had gestational diabetes->8 I Diabetes V1.2 Page 2 of 7
3 have been pregnant but I have never had gestational diabetes->19 I have never been pregnant->19 ->19 ) Question 8: Did you take medicine for gestational diabetes? and I did not take medication Question 9: At what age was the type 1 diabetes diagnosed? Question 10: Are you taking medicine for the type 1 diabetes? and I do not take medication Routing rule: ( ->11 ->12 and ->11 I do not take medication->19 ->19 ) Question 11: Was insulin your first diabetes medicine? Diabetes V1.2 Page 3 of 7
4 Yes No Question 12: At what age was the type 1 diabetes first treated? Question 13: At what age was the type 2 diabetes diagnosed? Question 14: Are you taking medicine for the type 2 diabetes? and I do not take medication Routing rule: ( ->15 ->16 and ->15 I do not take medication->17 ->17 ) Question 15: Was insulin your first diabetes medicine? Diabetes V1.2 Page 4 of 7
5 Yes No Question 16: At what age was the type 2 diabetes first treated? Question 17: Did you ever have gestational diabetes during pregnancy before you were diagnosed with type 2 diabetes? Yes, I have been pregnant and have had gestational diabetes I have been pregnant but I have never had gestational diabetes I have never been pregnant Routing rule: ( Yes, I have been pregnant and have had Gestational Diabetes->18 I have been pregnant but I have never had Gestational Diabetes->19 I have never been pregnant->19 ->19 ) Question 18: Did you take medicine for gestational diabetes? and I did not take medication Diabetes V1.2 Page 5 of 7
6 Question 19: Does anyone in your family have type 1 diabetes? Select all that apply Father Mother Sibling Child None of the above Gender specific: None Question 20: Does anyone in your family have type 2 diabetes? Select all that apply Father Mother Sibling Child None of the above Gender specific: None Question 21: How would you rate this survey? No comment. Diabetes V1.2 Page 6 of 7
7 I can imagine it is useful for research. It was interesting. It could use some work. Gender specific: None Routing rule: ( END ) Diabetes V1.2 Page 7 of 7
New Patient Questionnaire
New Patient Questionnaire Date of appointment (MM/DD/YYY): Name (Last, First, MI): Previous Names: DOB (MM/DD/YYY): Phone: Cell: Email: May we email you with sensitive information, such as test results?
Early Teen Interview
I. STUDY NUMBER II. EVENT II. TODAY S DATE / / III. RA INITIALS IV. SITE 1 KENMORE 2 HOME 9 OTHER Early Teen Interview Okay, great. So, let s start the interview. I d like to begin by stressing that there
Patient Information. Name: (Last) (First) (Middle) Address: (Street) (City) (State) (Zip) Home Phone: Cell Phone: address:
Patient Information Name: (Last) (First) (Middle) Address: (Street) (City) (State) (Zip) Home Phone: Cell Phone: Email address: Birth date: _ Age: Social Security.: When is the best time to contact you?
BAYLOR SCOTT & WHITE HEALTH GENETICS QUESTIONNAIRE PATIENT INFORMATION
PATIENT INFORMATION Name: Address: (Last) (First) (Middle) (Street) (City) (State) (Zip) Home Phone: Cell Phone: Email Address: Birth Date: Age: When is the best time to contact you? May we email you for
New Patient History Patient Name: Age: Date of Birth:
New Patient History Patient Name: Age: Date of Birth: Is there a physician you would like us to send a letter about your visit/progress here? If yes, please provide their name, address & office phone number:
Cancer Genetics Baylor All Saints Medical Center at Fort Worth
Cancer Genetics Baylor All Saints Medical Center at Fort Worth Thank you for your interest in the Hereditary Cancer Risk Program (HCRP). Please complete the family history and risk factor questionnaire
Screening for sickle cell disease and thalassaemia. An easy guide to screening tests when you are pregnant
Screening for sickle cell disease and thalassaemia An easy guide to screening tests when you are pregnant Contents: what is in this booklet Page Your choice 3 About these tests 4 Sickle cell disease 6
PATIENT INFORMATION. (Last) (First) (Middle) (Last) (City) (State) (Zip)
PATIENT INFMATION : Address: (Last) (First) (Middle) (Last) (City) (State) (Zip) Home Phone: Cell Phone: Email address: Birth date: : Gender: When is the best time to contact you? May we email you for
Hereditary Cancer Risk Program
Hereditary Cancer Risk Program Family History and Risk Assessment Questionnaire Please answer questions to the best of your ability in order to help us establish your risk assessment. Write in unk (unknown)
CENTER FOR HUMAN REPRODUCTION - CHR 21 East 69 th Street, New York, N.Y., Telephone: ; Fax:
CENTER FOR HUMAN REPRODUCTION - CHR 21 East 69 th Street, New York, N.Y., 10021 Telephone: 212.994 4400; Fax: 212.994 4499 PATIENT QUESTIONNAIRE (Please complete entire questionnaire prior to initial consultation
Nathan Driskell, MA, LPC, NCC
Nathan Driskell, MA, LPC, NCC https://nathandriskell.com New Client Questionnaire/Psychosocial History (To be completed by the client) Please complete this form to the extent that you feel comfortable.
Developmental-Behavioral Pediatrics Questionnaire for New Patients
Developmental-Behavioral Pediatrics Questionnaire for New Patients Date: Name of person completing questionnaire: Relationship to child: Email: IDENTIFYING INFORMATION: Information Child Name Child Birthdate
HRSA-UIC Perinatal Depression Project: Tool for Assessment of Stressors in Depression during Pregnancy & Postpartum
HRSA-UIC Perinatal Depression Project: Tool for Assessment of Stressors in Depression during Pregnancy & Postpartum te to health care provider: This tool is a guide to assessing psychosocial stressors
New Patient Information Form
New Patient Information Form Patient Identification Prenatal Alcohol & Drug Exposure Clinic FASD CLINIC Patient s OHIP N. Female Male Race Patient s Name Birth Date Age First Middle Last Patient s Address
Cancer Risk Assessment Questionnaire
Information about your health, lifestyle, and family history will help us determine your risk for cancer. If you already have cancer, it can help us determine the chance your cancer was caused by an inherited
Patient Information Form
1 Today s Date: Patient s Name Date of Birth Your Name Relationship to Child Name of School Grade Teacher(s) Please list the problems with which you want help for this child: 1. 2. 3. 4. 5. 6. 7. Has the
Johnson City Internal Medicine 301 Med Tech Parkway, Suite 240, Johnson City, TN (423)
IDX# Johnson City Internal Medicine 301 Med Tech Parkway, Suite 240, Johnson City, TN 37604 (423)794-5823 SoFHA Diabetes Clinic Assessment Instructions: Please complete and bring to your appointment with
CHILD APPLICATION NACD CENTER FOR SPEECH AND SOUND
549 25 TH STREET OGDEN, UT 84401-2422 CHILD APPLICATION NACD CENTER FOR SPEECH AND SOUND EFFECTIVE FEBRUARY 2011 CHILD S NAME Attach a small photo here CLIENT HISTORY Child Center for Speech and Sound
CMBHS Clinical Management of Behavioral Health Services
Client: CMBHS Clinical Management of Behavioral Health Services Case Management AST022 Assessment Information Assessment Number Assessment Date Assessment Type Contact Type Assessment Site Referred By
Objectives. Types of HIV Tests. Age Appropriateness of Tests. Breastfeeding and HIV Testing. Why are there different tests for different ages?
Objectives At the end of the lesson participants will be able to: Identify the types of HIV tests available in Botswana State who should be tested Identify which tests are used for infants and children
UNIVERSITY OF WASHINGTON
UNIVERSITY OF WASHINGTON THE FETAL ALCOHOL SYNDROME DIAGNOSTIC AND PREVENTION NETWORK (FAS DPN) Center for Human Development and Disability Dear Sir or Madam, Thank you very much for your request for an
Cancer Genetics Risk Assessment Program Questionnaire
We greatly appreciate you taking the time to complete this questionnaire and look forward to meeting you. Gathering this information prior to your appointment will help make your visit with us as efficient
ADHD SCREENING & DEVELOPMENTAL QUESTIONNAIRE: FOR PARENT TO COMPLETE
*PAPERWORK MAY BE MAILED, FAXED OR DROPPED-OFF (If faxing, send to: FAX: 585-244-9995 - Attention: Holly) ADHD SCREENING & DEVELOPMENTAL QUESTIONNAIRE: FOR PARENT TO COMPLETE Child s Name: DOB: Grade in
Evergreen Behavioral Health Psychiatric Intake Form. Name: Date: Date of Birth:!
Name: Date: Date of Birth: NOTE: Please also fill out the standard Evergreen Behavioral Health Adult Client Information form to accompany this one if you have not yet done so. Please also bring in recent
Diabetes. What is it and how can we prevent it? - Brigette Pereira and Natalie Wowk- Slukynsky, First Nations and Inuit Health Branch
Diabetes What is it and how can we prevent it? - Brigette Pereira and Natalie Wowk- Slukynsky, First Nations and Inuit Health Branch What is Diabetes? Diabetes is a disease where your body is not able
PERSONAL INFORMATION. Last Name: First Name: MI: Name of Spouse/Partner/Significant Other: Social Security Number: - - Drivers License No.
Date Form Completed / / Medical and Bariatric History The following information is very important to your health. Please take the time to fully and completely fill out this important information. PERSONAL
Blood Types and Genetics
Blood Types and Genetics Human blood type is determined by codominant alleles. An allele is one of several different forms of genetic information that is present in our DNA at a specific location on a
PATIENT HEALTH HISTORY FORM:
PATIENT HEALTH HISTORY FORM: It is very important to know your detailed medical history information to assess your health. Obesity and its associated diseases and risk factors increase mortality and surgical
GeMS Young Adult Self-Report Questionnaire
Patient Name: D.O.B: MRN: GeMS Young Adult Self-Report Questionnaire This form will help us learn about you prior to your appointment in GeMS. It asks about your gender identity experience, mental health,
Has your child ever received a speech and language evaluation? if so, when? Has he/she attended therapy?
Today s Date: Cleft Palate and Craniofacial Speech Disorders - Intake Form Welcome to Momentum Therapy Center. The information you provide on this form will help us prepare your child s upcoming speech-language
Screening for sickle cell disease and thalassaemia. An easy guide to screening tests when you are pregnant
Screening for sickle cell disease and thalassaemia An easy guide to screening tests when you are pregnant 1 Inside this booklet Page Your choice 3 About these tests 4 Sickle cell disease and thalassaemia
Opioid Treatment Center Application
PLEASE FILL OUT ALL AREAS COMPLETLY Name: Date: Maiden Name or Aliases: Address: Phone: Date of Birth: SSN#: Gender: Male Female Referral Source: Phone #: Annual Family Income: SSDI SSI Other Income Insurance
Intake Form. Date: Referred By: Name: Phone Number: Religious Affiliation: Where are you currently staying? City?
Intake Form Date: Referred By: Name: Phone Number: Email: Religious Affiliation: Where are you currently staying? City?: Birthdate: Age: Place of Birth: Citizenship: Race: Social Security Number: Marital
HOW DID YOU HEAR ABOUT US?
427 Bloomfield Ave. Ste. 306 Montclair, NJ 07042 Phone: 973-746- 2848 Fax: 973-746- 2088 HOW DID YOU HEAR ABOUT US? Eastern School of Acupuncture and Traditional Medicine Student Clinic Intake Form Intake
Lifestyle & Pre-diabetes Questionnaire
Please complete this questionnaire. The time you take to provide this information will help your health care team work better for you. General, Medical and Health Information Date: Name: Age: Race: Current
Complete Chiropractic Care
Complete Chiropractic Care CLINICAL NUTRITION HEALTH QUESTIONNAIRE Mr/Mrs/Ms/Miss/Mst: Surname: First Name: Occupation Address Suburb P/C Telephone (H) (W) (M) Date of Birth Marital status e-mail Partners
A Guide for Understanding Genetics and Health
2 Does it Run in the Family? A Guide for Understanding Genetics and Health u n i v e r s i t y o f o k l a h o m a health sciences center Contents Why is genetics important to my family and me? 1 What
REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY GROUP
REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY GROUP NEW PATIENT EVALUATION FORM Name: Age: Partner: Age: Reason for Referral: Date of Appt: Have you ever seen any other physician(s) for this problem? Name:
THE EMERGE SURVEY ON TAKING PART IN BIOBANK RESEARCH: VERSION A
THE EMERGE SURVEY ON TAKING PART IN BIOBANK RESEARCH: VERSION A What is this survey about? This survey is about your views on taking part in medical research. We want to understand what you think about
Gishela Satarino, MA, LPC-S 6750 Hillcrest Plaza Drive, #203 Dallas, TX History Form for Counseling Services
Gishela Satarino, MA, LPC-S 6750 Hillcrest Plaza Drive, #203 Dallas, TX 75230 214-280-3664 History Form for Counseling Services Client s Name: Age: Today s Date: / / Client s Sex: Client s Birthplace:
Feil & Oppenheimer Psychological Services
Feil & Oppenheimer Psychological Services 260 Waseca Ave. Barrington, RI 02806 401-245-4040 Fax: 401-245-1240 feiloppenheimer@gmail.com Adult Patient Questionnaire Name: Today's Date: Address: Home Phone:
The StrongWomen Program
A National Fitness Program for Women Cooperative Extension Service 1675 C Street, #100 Anchorage, AK 99501 Leslie Shallcross, M.S., R.D., L.D. Associate Professor of Extension 907-786-6300 Name Address
Lessons from conducting research in an American Indian community: The Pima Indians of Arizona
Lessons from conducting research in an American Indian community: The Pima Indians of Arizona Peter H. Bennett, M.B., F.R.C.P. Scientist Emeritus National Institute of Diabetes and Digestive and Kidney
Sexually transmitted disease prevention: knowledge, attitudes, and practices among school pupils in rural Ghana
Sexually transmitted disease prevention: knowledge, attitudes, and practices among school pupils in rural Ghana Duong Le Quyen, Kathleen Kahn, Cornelius Debpuur Most people have sex in their teen years
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Calorie Booster Revision. Melissa Misley
Calorie Booster Revision Melissa Misley Previous calorie booster handouts Included these tips = Recipe included on new handout Previous calorie booster handouts Included serving size and calories Previous
ADULT PATIENT HISTORY FORM. Name: Address: City: State: Zip: Occupation (if applicable): Religious Affiliation (if applicable):
ADULT PATIENT HISTORY FORM DEMOGRAPHIC INFORMATION: Name: Address: City: State: Zip: Age: Date of Birth: Gender: Male Female Transgender Marital Status: Never Married Domestic Partners Married Separated
Name: DOB: Today s Date: Pre-diabetes Type 2 diabetes Gestational diabetes. Type 1 diabetes/latent Autoimmune Diabetes of Adults (LADA)
INTERNAL REFERRAL DIABETES HISTORY FORM Name: DOB: Today s Date: What type of diabetes do you have? Please circle: Pre-diabetes Type 2 diabetes Gestational diabetes Type 1 diabetes/latent Autoimmune Diabetes
Name of Recipient: Recipient s DOB (if known) Relationship to Recipient: (Example: mother, father, sister, brother, friend, etc)
The Christ Hospital Health Network DONOR REGISTRATION INFORMATION Phone: 513-585-2493 Fax: 513-585-0433 (Please be advised donor information is needed ONLY to register donor in the Christ Hospital system.
Association of a nicotine receptor polymorphism with reduced ability to quit smoking in pregnancy
Research Symposium, MRC CAiTE & Department of Social Medicine, University of Bristol, 3 rd March 2009. Association of a nicotine receptor polymorphism with reduced ability to quit smoking in pregnancy
Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
Fluency Case History Form
Jennifer Bauer, MA, CCC-SLP 970-590-6206 jennifer@bauertherapy.com www.bauertherapy.com Date: Fluency Case History Form Child s Name: Date of Birth: Male Female Home Address: Home Phone #: Form Completed
BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM
BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM Name Age Preferred first name Address City, State Zip Phone (Day) -_- Cell --_ Email address Occupation (indicate former occupation if retired)
TIME INTERVIEW BEGAN: Questionnaire for Unmarried Latino Women
TIME INTERVIEW BEGAN: Questionnaire for Unmarried Latino Women 1. When you were young, how often did your mother discuss sex with you? Would you say frequently, several times, a few times or never? 1 Frequently
Module 7: Case Discussion and Administration Technique
: Case Discussion and Administration Technique Miranda Wilhelm, Pharm.D. Clinical Associate Professor Department of Pharmacy Practice Southern Illinois University Edwardsville, School of Pharmacy 1 Disclosure
Diabetes Self-Care Assessment Date:
Diabetes Self-Care Assessment Date: Personal Information: Name: Are you: Married Single Widowed Other Do you live: Alone with Spouse with Others Do you have any condition that affects your ability to take
Gender: Male Female Age: Current Address: City: State: Zip Code: Work Phone: Is it okay to leave a message? VISIT INFORMATION
SIENA PROACTIVE INTERNAL MEDICINE DR. DEBORAH BLENNER 45 Terry Road, Suite B Smithtown, NY 11787 www.sienaproactive.com Phone: (631) 656-8171 Fax: (631) 656-8173 PATIENT INFORMATION Last Name: First Name:
Atlanta Psychological Services
Atlanta Psychological Services 2308 Perimeter Park Drive 770-457-5577 Suite 100 Fax 770-457-5599 Atlanta, GA 30341 atlantapsychological.com Check one: rev. 10-13-18 J. Todd George, PsyD Carolyn Johnson,
Please fill out the following information and have it returned to our office prior to your consultation.
Please fill out the following information and have it returned to our office prior to your consultation. Patient s Name Partner s Name Address: City: State: Zip: Phone (day#): ( ) (eve#) ( ) (cell) ( )
Chiropractic & Progressive Rehab HISTORY OF ILLNESS / INJURY / PAIN
Chiropractic & Progressive Rehab HISTORY OF ILLNESS / INJURY / PAIN LOCATION Chief complaint and its location: What caused the onset? Date of onset? / / TIMING AND DURATION How often do you experience
Development and Prediction of Hyperactive Behaviour from 2 to 7 Years in a National Population Sample
Development and Prediction of Hyperactive Behaviour from 2 to 7 Years in a National Population Sample Elisa Romano, Ph.D. University of Ottawa Richard E. Tremblay, Ph.D. Abdeljelil Farhat, Ph.D. Sylvana
Water Supply: City Well
Endocrine Information Sheet Please complete this endocrine information sheet and bring to your child s appointment. Date: Child s Name: Date of Birth: Age: Race/Sex Address: City: State: Zip Code: Home
Maternal food consumption during pregnancy and the longitudinal development of childhood asthma
Maternal food consumption during pregnancy and the longitudinal development of childhood asthma Saskia M. Willers, Alet H. Wijga, Bert Brunekreef, Marjan Kerkhof, Jorrit Gerritsen, Maarten O. Hoekstra,
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska 99518 (907)563 7700 PATIENT DEMOGRAPHICS Today's Date: Name: Birth Date: Age: Male
99 SOUTH ALCANIZ STREET SUITE B PENSACOLA, FL
KEVIN M. HOGAN, DC DEBRA HEMPHILL, ARNP ROBERT SAYRE, MD Clinic Director Advanced Registered Nurse Practitioner Medical Director Name: Address: City/State/Zip: Phone number: First Middle Last How did you
Inheritance. Children inherit traits from both parents.
Have you ever been told you have your mother s eyes or your father s smile? Have you ever noticed you share your grandfather s eye color or possibly your grandmother s curly hair, and yet your parents
Name: DOB: Today s Date: Pre-diabetes Type 2 diabetes Gestational diabetes. Type 1 diabetes/latent Autoimmune Diabetes of Adults (LADA)
NEW PATIENT DIABETES HISTORY FORM Name: DOB: Today s Date: What type of diabetes do you have? Please circle: Pre-diabetes Type 2 diabetes Gestational diabetes Type 1 diabetes/latent Autoimmune Diabetes
2550 Middle Road, Suite 316 Bettendorf, Iowa Adult Intake Form
Adult Intake Form 2550 Middle Road, Suite 316 Bettendorf, Iowa 52722 563.265.1529 annika@qcwomenstherapy.com Thank you for choosing Quad City Women s Therapy. I collect the following information help me
Johann Hari. Truths 2/29/2016. From the street to the NICU. Treatment works
From the street to the NICU Richard Christensen, PA, CAS Johann Hari Treatment works Truths Disconnect with pregnant women seeking treatment Disconnect between community and science Medication is not a
Information for fathers invited for a screening test for sickle cell disease and thalassaemia major
Information for fathers invited for a screening test for sickle cell disease and thalassaemia major Who is this leaflet for? This leaflet is for fathers invited to have a screening test for haemoglobin
NAME OF PERSON COMPLETING QUESTIONNAIRE: Relationship to child: Referred by*:
OREGON HEALTH & SCIENCE UNIVERSITY SLEEP DISORDERS MEDICINCE CLINIC PEDIATRIC SLEEP QUESTIONNAIRE SCHOOL AGED CHILDREN (4 12 year old) TO BE COMPLETED BY PARENT NAME OF PATIENT: DATE OF BIRTH: / / NAME
NEW CLINIC PATIENT QUESTIONNAIRE
Washington Heart Rhythm Associates, LLC Pirooz Mofrad MD, FACC, FHRS 10230 New Hampshire Avenue, Suite 204 Silver Spring, MD 20903 Telephone: 301-408-7890 Fax: 301-408-7892 NEW CLINIC PATIENT QUESTIONNAIRE
Family Health History
Family Health History Biological Family History Mother s and Father s Health History Diabetes o Mother o Father High Blood Pressure o Mother o Father Smoker o Mother o Father Kidney Problems o Mother o
Child s Information (Please print) Name Birth Date Age Home Address City State Zip Code
The following questions are asked so that we can best understand your child. Please fill out this questionnaire before the child is evaluated. Please read the questions carefully and answer them as fully
Pediatric Nutrition History
Please answer each of the questions below. The information you share will help the Registered Dietitian have a better understanding of your needs. - 1 - Patient Name D.O.B: 67Parent/Legal Guardian: Phone
Practitioner Assessment Form (PAF)
Practitioner Assessment Form (PAF) What is the PAF? The practitioner assessment form is a health assessment designed to assist the physician in collecting specific information on Medicare Advantage patients.
DESERT CENTER FOR ALLERGY AND CHEST DISEASES HEALTH QUESTIONAIRE NAME. PAST MEDICAL PROBLEMS- Check mark if you have any of the following
DESERT CENTER FOR ALLERGY AND CHEST DISEASES Pulmonary Medicine, Allergy/Immunology, Sleep Disorders Pulmonary Rehabilitation, Pulmonary Function Laboratory HEALTH QUESTIONAIRE NAME What is your presenting
Pediatric Sleep History
Fax 423-431-2983 Pediatric Sleep History Patient/ Child s Name: Date of Birth: Parent Name: Last 4 of Social Security No: Gender: Male Female Height: Weight: Age: Race: Street Address: City: State: Zip:
problems/medications: Current supplements/vitamins/herbs: Past medical problems/medications: Other doctors/clinics seen regularly:
Main Purpose of the consultation (Please give a brief summary of the main problems) What happened to make you seek evaluation at this time? MEDICAL HISTORY Current medical Prior Attempts to correct the
Diabetes in our Communities:
Diabetes in our Communities: National Results from the First Nations Regional Health Survey (RHS) 2015/16 April 18, 2018 National Indigenous Diabetes Conference Overview Introduction to the Regional Health
PEDIATRIC MEDICAL HISTORY QUESTIONNAIRE
Division of Otolaryngology Main Phone: 847 504-3300 Main Fax: 847 504-3305 Mihir Bhayani, MD Judy L. Chen, MD Mark E. Gerber, MD, FACS, FAAP Joseph Raviv, MD Ilana Seligman, MD, FACS, FAAP Michael J. Shinners,
Pregnancies complicated by diabetes. Marina Mickleson Nurse Practitioner Midwife CDE
Pregnancies complicated by diabetes Marina Mickleson Nurse Practitioner Midwife CDE Two types Pre gestational Gestational diabetes Both types are on the increase Pre conception work up is imperative for
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
PATIENT IDENTIFICATION: Name: First Appointment Date: Birth Date: Address: City State Zip Home Phone #: Work #: Cell #: REFERRAL SOURCE: Referred By:
Andrew E. Leifer, M.D., P.C. 1202 Bergen Parkway, Suite 211 Evergreen, Colorado 80439 General Adult Psychiatry Outpatient and Hospital Care Medical Consultation-Liaison Service Telephone (303) 674-6074
Genetic Risk Evaluation and Testing Program
INSTRUCTIONS: Please complete this form to the best of your ability PRIOR to your appointment. Please remember to list ALL relatives, both living and deceased, regardless of if they have had cancer or
Riley Sleep Evaluation Questionnaire
Directions Please answer each of the following questions by writing in or choosing the best answer. This will help us better understand your child and his or her sleep problems. Shade circles like Not
Humana Practitioner Assessment Form
Humana Practitioner Assessment Form Please fill in the information requested in this box only. Your physician will complete the remaining sections of this assessment. Patient name: Date of service: Humana
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES 13414 Medical Complex Drive, Suite 6 Tomball, TX 77375 281-516-0212 Welcome! We are glad that you have chosen Tomball Regional Internal Medicine Associates
Child and Youth Background Information
Child and Youth Background Information CHILD S NAME: SUBSTANCE USE HISTORY (for ages 12 and older or if applicable) Substance Type Current Use (last 6 months) Past Use: Please check and complete all that
Daytime support in Oxfordshire
Daytime support in Oxfordshire What do you think about our plans for change? Easy Read Contents Page What is this all about? 3 What do people need from support during the day? 4 Our aims for daytime support
Medical History. Participant Id#: Acrostic: Tech ID#: Date: / / 1 How would you say your health currently compares with other persons of your age?
Multi-Ethnic Study of Atherosclerosis Exam 5 Participant Id#: Acrostic: Tech ID#: Medical History Interviewer Administered Date: / / Month Day Year The following are some questions about your medical history.
NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name
NEW PATIENT FORM Please print in ink and fill in all blanks Please fill out front and back Patient s Full Name Date of Birth Age Sex Social Security Number Referring Doctor or Family Physician Phone #
The Johns Hopkins Diabetes Center JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT. Name: Marital Status: M S W SEP D
JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT Date: JHH # I. General Information Name: Marital Status: M S W SEP D Address: Phone: Home: Work: Email: Fax: Sex: M F Date of
QUESTIONNAIRE ON EATING AND WEIGHT PATTERNS-5 Child/Adolescent (QEWP-C-5)
PhenX Measure: Eating and Weight Patterns (#651200) PhenX Protocol: Questionnaire on Eating and Weight Patterns - Child (#651202) Date of Interview/Examination (MM/DD/YYYY): QUESTIONNAIRE ON EATING AND
9/9/2016. Drug Name (select from list of drugs shown) Bunavail Buccal Film (buprenorphinenaloxone) Suboxone Sublingual Film (buprenorphine-naloxone)
9/9/2016 Prior Authorization Form PASSPORT HEALTH PLAN KENTUCKY MEDICAID Buprenorphine Products This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
New Patient History. Patient Name: Date of Birth: Reason for Today s Visit: Today s Date: Who is your Primary Care Physician (PCP)?
ew Patient History Patient ame: Date of Birth: Reason for Today s Visit: Today s Date: Who is your Primary Care Physician (PCP)? Review of Systems Please circle any concerning symptoms you are currently
Gestational Diabetes
Gestational Diabetes GESTATIONAL DIABETES What is diabetes? Diabetes affects the way your body turns food into energy. When you eat, your body changes food into a sugar called glucose. Glucose is the fuel
Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:
Chinese Medicine Adult Intake Form Name (Last, First): Date of Birth: Occupation: Hours per week: Home address: Phone: Email: Preferred contact method (circle one): Phone / Email Emergency contact name
CHILD INTAKE (Please Print Clearly)
Jeremy Hayman, ND CHILD INTAKE (Please Print Clearly) Doctor of Naturopathic Medicine Child s name (First/Last) Date of birth (M/D/Y) Sex M F Referred by Who is filling out this form (name and relation)?
Inheritance of Gaucher Disease
Sarah Mother of a child with Gaucher Working toward a healthy future Helping her son achieve his own dreams, too Straight Talk For Patients and Families Inheritance of Gaucher Disease Genzyme Corporation