Renal Remission and Hypertension Consultants PLLC
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- Timothy Green
- 5 years ago
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1 Past Medical History. Please provide us with the list of your medical problems. Please indicate year of onset or when you became aware of it and year of resolution (if resolved) Problem Started Resolved 1
2 Please provide the list of surgeries you had, if any. Please include arterial angioplasties and stenting of the arteries Surgery Year Performed 2
3 Family History Please provide us with your family history. Put a checkmark if person is alive. Put current age if person is alive or age at death if the person has passed away. If you know the age (approximate is OK) at onset of the problem please write it in, otherwise put checkmark. If there are other relatives who have/had conditions listed below, please add them in the empty spaces at the end of the table. Mother Father Brother1 Brother2 Brother3 Brother4 Sister1 Sister2 Sister3 Sister4 Son1 Son2 Son3 Daughter1 Daughter2 Daughter3 Alive Age Kidney failure/ Dialysis Stroke/ TIA High Blood Pressure Heart Attack*/ age High Cholesterol Diabetes Other *Also please include Coronary Bypass surgery, Coronary strents, Angioplasty 3
4 Social History Are/were you married? Do/did you work? Where? What kind of work do you do/did there? Are you or have you been exposed to lead, cadmium, mercury or other heavy metals at your work or hobby? Habits Tobacco: Do you smoke or did you smoke? How much? At what age did you start smoking? At what age did you quit? Alcohol: Do you drink alcohol? How much? How frequently? Have you ever drank moonshine (self-distilled whiskey)? 4
5 Caffeinated beverages: Do you drink coffee, tea, hot chocolate, caffeinated sodas? How much? Salt: Are you on a low salt diet? Do you buy prepared foods? Do you have a salt shaker on your table? Over the counter medications and supplements: Are you taking any over the counter anti-inflammatory medications (Ibuprofen, Motrin, Advil, Naprosyn, Aleve, aspirin) or headache medications? How many pills per day? For how many years? Are you taking any herbal or holistic medications? Please write down the names: Are you using any medications/supplements to help weight loss? Please write down the names: Are you using cocaine or methamphetamines? Please describe your usual exercise routine: 5
6 Allergies: Do you have any allergies to food or medications? If no, proceed to the next page. Please describe medication and food allergies: Medication Year when occurred Nature of allergic reaction (rash, wheezing, shock, etc.) For office use, please leave blank Are you allergic to: Name of medication/ food: Yes No Not Sure Penicillin Aspirin Iodine Seafood Blood pressure medications 6
7 List of Current Medications Please list all the medications, including over-the-counter medications that you are currently taking and how many times a days are you taking it: Medication Name How Many Times a Day 7
8 Review of Systems: Please fill in answers into the table by placing checkmark in appropriate field: Do you have or recently had: Yes No Not sure 1 Fever, chills or night sweats 2 Weight loss 3 Worsening fatigue 4 Skin rash of any kind 5 Hearing problems 6 Inflammation of the eye 7 Bloody/discolored sinus drainage 8 Strep throat 9 Coughing up blood 10 Worsening shortness of breath 11 Chest pain 12 Fast or irregular heart beats 13 Increase in the size of the abdomen 14 Bloody diarrhea 15 Increased frequency of urination 16 Blood in the urine 17 Coke-colored urine 18 Swelling of the ankles 19 Swelling, pain and warmth of the joints 20 Persistent numbness and/or pain in the feet Have you ever had: Yes No Not Sure Blood transfusion Jaundice Hepatitis Lupus Risk factors or exposure to HIV Kidney Stones Gout 8
9 Hypertension questioner: Please answer these questions if you are referred for hypertension management or have hypertension. When was the last time you were told that your BP is normal (while not on medications to treat blood pressure)? When was the first time you were told that your BP is NOT normal? What was the typical BP reading 1 year ago? What was the typical BP reading 5 years ago? What was the typical BP reading 10 years ago? Please take your time over the next several days to check and record in the table below your BP at specified times of the day (if you own or can borrow one for a few days a blood pressure monitor). Date BP in AM before meds BP in AM 2 hours after AM meds BP in PM before meds and/or dinner BP in PM 2 hours after meds and/or dinner BP before bedtime Please bring all your prescriptional, over-the counter, herbal medications and other supplements to your appointment. Please bring your blood pressure monitor to your appointment to be checked for accuracy. 9
10 Please fill this form if you were told you have protein or blood in your urine Have you ever had Urine Analysis (UA) performed? UA is usually performed as part of the screening examination, regular physical exam or to evaluate specific complaints. UA is almost always performed during pregnancy, usually several times. If you have not had or do not remember UA performed go to the next page. When was your first UA performed? When and where was your last UA performed? How often have you had UA performed in between? When was the last time you had normal UA? When was the first time you were told that your UA was NOT normal? Who was your doctor at that time? What was not normal in the urine? Yes No Not sure Protein in the urine Blood in the urine White blood cells (sign of infection) in the urine? Anything else abnormal in the urine? What was not normal in the urine? Yes No Not sure Protein in the urine Blood in the urine White blood cells (sign of infection) in the urine? 10
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
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
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY NAME: _ DATE: Please complete the following questionnaire as completely as possible. 1. MEDICAL HISTORY Please list all current and prior health problems,
Name of Pa. tient: Last. First. per day) 50 mg. X-ray dye or. IV contract. Name (Last) (First) Address. City, state/ zip code
Division of Cardiology for the Academic Medical Center of the University of Texas Medical School at Houston NEW PATIENT HISTORY FORM Please complete and fax to 713-512-2245 Name of Pa tient: Last _ First
ALLERGIES 8. Have you ever had any allergic reaction (bad effect) to a medicine or shot?
Adult Health History Legal Name: First Last Name you like to be called: Date of Birth: Legal sex: Male Female X Gender: Woman Man Trans Woman Trans Man Non-binary Genderqueer Agender Not Listed: Filling
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
Patient Name Date Referring M.D. Occupation Married Divorced Single Widowed
Patient Name Date Referring M.D. Birth date / / Age Explain your reason for the visit: Occupation Married Divorced Single Widowed Abdominal pain No yes Intensity of the pain/ Mild /moderate/ severe /10
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Patient History Form
Acct #: Patient History Form Please answer ALL questions by filling out the appropriate box(es). Name: Gender: M F Primary Care Provider: DOB: Today s Date: Referring Provider (if different from PCP):
Please complete and return to the office prior to your appointment.
Please complete and return to the office prior to your appointment. Name: Last:, Today s Date: First: MI: Nickname: Date of Birth: Age: Sex: M F SSN: Parent/Legal Guardian (if the patient is a minor):
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
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Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
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RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
MEDICAL HISTORY (To be filled in by patient)
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New Patient Medical Questionnaire DATE:
New Patient Medical Questionnaire DATE: Patient Name: DOB: AGE: Other Physicians: Who can we thank for referring you to our practice? Pharmacy Name & Location:` Phone # CHIEF COMPLAINT What problems are
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Patient Information Form Date: Name: First MI Last Address: Street Apt City State Zip Code Date of Birth: Social Security Number: - - Home Phone: Work Phone: Cell Phone: Email: Primary Language: (Fill
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PATIENT INFORMATION Please print clearly and complete all blanks
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*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
GIDEON G. LEWIS, M.D.
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BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
Patient Interview Form
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Gender: M F Race: Caucasian African American Hispanic Other
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MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
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Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Race (Check one): White Black Asian American Indian/Eskimo/ALEU Hawaiian Native/Pacific Islander Other
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Name. Date of Birth. Primary Care Doctor? Who is the Doctor that referred you to us? Name of person completing this form?
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JOHN MICHAEL ROACH, MD
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Athens Rheumatology Clinic, LLC Sana Makhdumi, MD
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD Phone: 706-850-8322 Fax: 706-850-8322 PATIENT HISTORY FORM Date of first appointment: / / Time of appointment: Birthdate: Name LAST FIRST MIDDLE INITIAL
This form is long! Please feel free to have the doctor or medical staff help you to complete it if you need any assistance at all.
Welcome! This form helps us to meet your medical needs and to provide the best service to you. If you have any questions or need assistance, please ask us. GENERAL PATIENT INFORMATION Name: Home Phone: