Name Age Est Weight Height. In brief, why are you seeing the doctor today? List your allergies: List your medications, including dosages:
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1 Date: Name Age Est Weight Height In brief, why are you seeing the doctor today? List your allergies: List your medications, including dosages: Previous Biopsies? Where Previous Surgery/Hospitalization/Injuries/Severe Illness Have you had cancer? Yes No Year Where What What kind? Have you had Chemotherapy? Have you had radiation? QUESTIONS FOR WOMEN: # of Children delivered Ages C-Section? Complications Last GYN Exam Last PAP Being treated for menstrual problems? Could you be pregnant? Do you have now: false teeth, caps on your teeth, artificial joints, tissue implants? Do you require the assistance of: a walker, crutches, artificial limb, wheelchair, other? Do you currently smoke, dip or chew, if so # per day? Have you used tobacco in the past 24 months? If you drink alcohol, # per week? Family History: heart disease, hernia, anesthetic reactions, cancer, diabetes, kidney cysts or kidney failure, known inherited diseases, breast cancer, colon polyps, pulmonary embolism, phlebitis or blood clots, other? (circle) Other: Social/Occupational History: Occupation If retired, what did you do? Frequently lift over: 10, 25, 50, 100 lbs (circle) Frequently: bend, squat, crawl, climb stairs, work in dirty or unclean conditions, sweat (circle) Do you live alone? with spouse or partner? with children? with other? (explain) If you live alone, do you require someone to help you with your daily driving? meals? bathing? Do you live in a nursing home or assisted care facility? Have you ever had an injection, IV, or gas for anesthesia? Yes No If yes, did you have any problems? Who do you authorize the release of medical information to? May we leave a message on your answering machine/voic ? Yes No Referring Physician: Primary Physician: 1
2 GEN/CONSTITUTIONAL: LOSS OF APPETITE DEPRESSION WEAKNESS WEIGHT GAIN WEIGHT LOSS FATIGUE STRESS UNABLE TO SLEEP EYES: RECENT CHANGE IN VISION OR SURGERY BLURRED VISION EYE PAIN DIMMING OF VISION ITCHING OR RED EYES LID SWELLING LIGHT SENSITIVITY SEE FLASHING LIGHTS OR SPOTS EARS NOSE THROAT: SINUS CONGESTION OR BLOCKAGE OF BREATHING HEADACHES NOSE BLEED HOARSENESS OR VOICE CHANGE HEARING LOSS OR RINGING DENTURES DIFFICULTY SWALLOWING MOUTH SORES RESP: CHRONIC OR NEW COUGH OR NIGHT COUGH OR CHOKING ASTHMA OR WHEEZING SHORTNESS OF BREATH PRIOR ANESTHESIA PROBLEMS TUBERCULOSIS EMPHYSEMA OR COPD OR FREQUENT PNEUMONIA OR BRONCHITIS COUGHING UP BLOOD NIGHT SWEATS 2
3 CARDIOVASCULAR: STROKE OR CVA OR TIA SEVERE CHEST PAIN OR HEART ATTACK IRREGULAR HEARTBEAT OR PALPITATIONS OR VALVE PROLAPSE VARICOSE VEINS SWELLING IN LEGS OR ANKLES OR FEET LEG PAIN WITH WALKING OR FOOT/TOE PAIN AT NIGHT HIGH BLOOD PRESSURE OR TREATMENT FOR HYPERTENSION DIFFICULTY BREATHING AT NIGHT GASTROINTESTINAL: ABDOMINAL PAIN OR ACHE OR BURN OR CRAMPING CONSTIPATION DIARRHEA YELLOW JUANDICE OR HEPATITIS LIVER CIRRHOSIS VOMITING BLOOD OR COFFEE GROUNDS OR PASSING BLOOD OR BLACK BOWEL MOVEMENTS NAUSEA OR VOMITING HEARTBURN OR REGURGITATION OR BURNING IN CHEST HEMORRHOIDS GENITOURINARY MALE: PAINFUL OR DIFFICULT URINATION PAINFUL INTERCOURSE OR IMPOTENCE UP TO PASS WATER MORE THAN ONCE AT NIGHT LOSSING URINE OR PASSING WATER WITH COUGH OR SNEEZING OR INVOLUNTARILY ABNORMAL DRAINAGE, HERPES OR SYPHILLIS OR GONORRHEA KIDNEY STONES A BLOODY OR BROWN OR SMOKY URINE KIDNEY OR BLADDER OR PROSTATE INFECTIONS GENITOURINARY FEMALE: DELIVERED CHILDREN BLOOD IN URINE OR VAGINA PAINFUL MENSTRUATION LOSS OF URINE WITH COUGH OR SNEEZE OR OTHERWISE NOT CONTROLLED BLADDER OR KIDNEY INFECTION GONORRHEA OR SYPHYLLIS OR CHAMYDIA OR HERPES PELVIC INFECTIONS URINARY STONES 3
4 ENDOCRINE: DO YOU OR YOUR FAMILY HAVE DIABETES? LOW BLOOD SUGAR OR PASS OUT EASILY LOW THYROID HIGH THYROID HOT FLUSHES WITH WEAKNESS COLD INTOLERANCE REALLY SEVERE ED HEADACHE UNED PERIOD OF SEVERE WEAKNESS MUSCULOSKELETAL: ARTHRITIS OR JOINT PAIN FIBROMYALGIA OR MUSCLE TENDERNESS OR ACHE BACK PAIN OR PAIN DOWN LOW BACK INTO BUTTOCKS OR LEGS CRAMPS IN BUTTOCK OR THIGH OR ARM OR CALF MAJOR INJURIES OR SURGERY NECK INJURIES OR SURGERY NEED CRUTCH OR WALKER OR WHEEL CHAIR FRACTURES OR BROKEN BONES SKIN: CANCER EASY BRUISING COLOR CHANGE ITCHING NEW DARK MOLES SCARS TEND TO BE UGLY TATOOS RASHES OR IRRITATION OR REDNESS OR CRACKING SKIN OR NAIL NEUROLOGIC: HEADACHES OR MIGRAINES PRIOR CONCUSSION VERY PAINFUL OR SENSITIVE AREAS ON BODY TO TOUCH OR PRESSURE CONVULSIONS OR SEIZURES OR EPILEPSY EASY FAINTING OR BLACKOUTS PERIODS OF MEMORY LOSS BALANCE PROBLEMS OR FREQUENT FALLS VERY WEAK OR PARALYZED PARTS OF YOUR BODY 4
5 PSYCHIATRIC: LOTS OF INAPPROPRIATE ANXIETY OR FEAR UNREASONABLE ANGER AND LOSS OF CONTROL DEPRESSION OR LOSS OF INTEREST SLEEP PROBLEMS UNED FATIGUE VOICES IN HEAD OR HALLUCINATIONS OR SUICIDAL THOUGHTS CONCERNED THAT YOU ARE LOSING CONTROL ALCOHOL OR OTHER DRUG/MEDICATION ABUSE. BREASTS: BREAST PAIN SWELLING LUMPS OR NODULES NIPPLE DISCHARGE SURGERY OR BIOPSY FAMILY HISTORY OF BREAST CANCER OR OVARIAN CANCER ABNORMAL MAMMOGRAM OR ULTRASOUND FIBROCYSTIC DISEASE HEMATOLOGIC/LYMPHATIC: LUMPS IN THE NECK OR UNDER ARMS OR GROIN BRUISE OR BLEED EASILY ANEMIA BLEEDING PROBLEMS IN YOUR FAMILY HAVE YOU HAD A BLOOD TRANSFUSION? LUPUS OR RHEUMATOID ARTHRITIS HEAL POORLY OR SLOWLY SERIOUS BLEEDING AFTER SURGERY I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. Signature Date 5
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NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C. Past Medical History AIDS/HIV disease Anemia Asthma Bronchitis Cancer Date of last Chest X-ray Diabetes Mellitus, Type I Diabetes Mellitus,
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
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.
PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:
1 NAME: DATE OF BIRTH PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS: PAST MEDICAL HISTORY (YOUR MEDICAL HISTORY) :
THE OB/GYN CENTRE NEW PATIENT HISTORY
PERSONAL PROFILE NAME: AGE: NAME YOU WOULD LIKE US TO USE: OCCUPATION: MARITAL STATUS: GYNECOLOGICAL HISTORY LAST MENSTRUAL PERIOD (FIRST DAY): AGE PERIOD BEGAN: PRESENT BIRTH CONTROL PAST METHODS OF BIRTH
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
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
On the day of your appointment we ask that you do not wear any lotion, oil or powder. This may affect the results of the EMG/NCV testing.
Phone: 907.563.8876 Fax: 907.762.6390 3801 University Lake Drive Anchorage, AK 99508 Dear Patient: Enclosed you will find a questionnaire regarding your past medical history and your current concerns.
Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP
UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
Health History Intake Form;
Health History Intake Form; Today s Date: Patient Name: Date of Birth: Age: Previous Primary Care Physician (if any): Phone: Address: Other Physicians involved in your care: Reason for visit today: Allergies
NEW PATIENT INFORMATION FORM
UNIT NUMBER PT. NAME UCSF Medical Center AMBULATORY SERVICES BIRTHDATE LOCATION DATE Today s Date / / What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician
Breast Care Patient Questionnaire. Name: Account: When did you first become aware of the problem with your breast?
Breast Care Patient Questionnaire Name: Account: Today s date: / / Height: ft in Weight: lbs. Birth date: / / Age BREAST HISTORY: Reason for visit: Symptoms (see list below), which I noted on routine exam