Patient Workup Tips 8/9/2018

Size: px
Start display at page:

Download "Patient Workup Tips 8/9/2018"

Transcription

1 Patient Workup Tips VisionAmerica Huntsville Start With Why Why Helps focus on the patents needs, wants, and/or desires Efficient use of resources Achieve the best outcome for all concerned 1

2 The How Varies A LOT by Office Doctor Context Learn your Office/Doctor The more you do, the better you get Review outcomes of interesting cases The What History Reason for Visit/Chief Complaint HPI (History of present Illness PFSH (Past Family Social History) ROS (Review of Systems) Vital Signs Systemic Ophthalmic What Workup Ancillary Tests Special Diagnostic Test alan.peaslee@eyehealthpartners.com 2

3 Reason for visit Why is the patient here? What the appointment reason says What the patient says What the staff and doctor think The real reason they are here Reason for visit Appointment: Complete exam Patient: My vision is blurry Staff/Doctor think: Routine exam The real reason: New vision plan and they want new glasses and contacts Reason for visit Appointment: Complete exam Patient: I want my eyes checked Staff/Doctor think: Routine exam The real reason: Sister was just diagnosed with glaucoma and they worried they might have glaucoma alan.peaslee@eyehealthpartners.com 3

4 What to record in the chart Danger Will Robinson, Danger! What you record as reason for visit can make all the difference for when it comes to 3 rd party coverage Be clear with your doctor regarding Routine exam Complete exam No complaints Wants new glasses/contacts What to record in the chart Look back at last visit plan Patient returns for evaluation of. Dry eye Cataract Glaucoma Ect... History related to the reason stated above Patient also requests History alan.peaslee@eyehealthpartners.com 4

5 Medical History Why Listen to Your Patient; He s Telling You the Diagnosis! William Osler, MD On of the Fathers of modern Medicine ( ) Principals and Practice of Medicine ( ) The Case History Never Ends! James Marbourg, OD One of the fathers of Optometry in Alabama From the beginning of time to the present alan.peaslee@eyehealthpartners.com 5

6 History Detective History Detective Patients will tell you things that they don t or won t tell the doctor Patients will tell the Doctor things that they don t or won t tell you WHY? History Detective Member of same (or opposite) gender They remember later They intentionally withhold It s not important, it s just an eye exam Want an unbiased opinion/second opinion They are embarrassed They don t trust us..yet Don t take it personally alan.peaslee@eyehealthpartners.com 6

7 History Structure HPI History of Present Illness 8 Elements PFSH Past Family Social History 3 Components ROS Review of Systems 14 Elements Orientation/Affect History of Present Illness (HPI) 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying factors 8. Associated signs and symptoms History of Present Illness (HPI) Location: Where is the problem OD, OS, OU, Right worse then left Quality: What is the nature of the problem Pain, Redness, Discharge,light sensitive Severity: 1 10 Scale, Mild, Moderate, Severe, Worst ever Duration: How long Hours, Days, Weeks, Months.YEARS alan.peaslee@eyehealthpartners.com 7

8 History of Present Illness (HPI) Timing: Worse in the morning or evening Constant, intermittent, variable Context: Associated with any activity? Reading, Driving at night, bending over Modifying factors. Effort to improve the problem? Heat, Tears, their Child s pink eye drops? Associated signs/symptoms: Headache, Twitching, Excessive tearing, Light sensitive History of Present Illness (HPI) Need AT LEAST 4 Elements: Patient c/o red painful eye, R>L x 4 days, constant mild pain, not getting worse, itchy/watery discharge, cold rag helps, worse outside. 1) Quality: red painful 2) Location: R>L 3) Duration: 4 days 4) Timing: constant 5) Severity: mild pain 6) Assoc Signs/Sym: Itchy/watery 7) Mod Factor: cold rag 8) Context: outside History of Present Illness (HPI) alan.peaslee@eyehealthpartners.com 8

9 Past, Family Social History Past (Patient) History Medical/Surgical History Current Medications Ocular/Ocular Surgery History Current Ocular Medication Past (Patient) History Medical Hypertension How long? Controlled When do they take HTN Medication Diabetes Type 1 vs. 2 Insulin use How long? Controlled FBS/A1C Surgical History Bariatric Surgery Heart Surgery Current Medications RX, OTC, Nutritionals Implanted delivery devices Birth control Why: Implanted birth control induced Papilledema alan.peaslee@eyehealthpartners.com 9

10 Causes of Pseudotumor Birth Control Tetracyclines Excess Vit A Past History Medications can be a clue undisclosed, significant History Why do you take.. Medication Reconciliation Dosage Quantity Frequency Route Past Ocular History Glasses History First Glasses Multiple pairs Ocular Surgery Refractive Surgery PRK/LASIK/RK/AK Myopic/Hyperopic Laser Sx Glaucoma Surgery Cataracts Contact lens History How often do you sleep in your contacts How often do you replace your contacts What solution do you store your contacts in alan.peaslee@eyehealthpartners.com 10

11 Ocular Medications Medication by cap color Blue/Green = PGA Yellow = Beta Blocker Light Green = Simbrinza Purple = Brimonidine Blue = Combigan Pink = Steroid Orange = CIA Over the Counter Tears Gels/Liquigels Ointments Allergy drops xxxxcon A (Vasocon A) Zaditor/Alloway Family History Family History Medical Ocular Diabetes Glaucoma Heart Disease Macular Degen Cancers Dry eye Kidney Disease Droopy lids Stroke Lazy eye Hypertension Glasses Social History Relevance can be very contextual Questions can be uncomfortable Marital status Sexual History Living arrangement Elderly Children Vocation/Avocation Unprescribed drug use Alcohol use/abuse Tobacco use/history alan.peaslee@eyehealthpartners.com 11

12 Review of Systems Review of Systems (ROS) 14 elements 1. Eyes 2. Constitutional 3. ENT Ears, nose, throat 4. CV Cardiovascular 5. Resp Respiratory 6. GI Gastrointestinal 7. GU Genitourinary 8. Integumentary (Skin) 9. Neurological 10. Musculoskeletal 11. Hemato/lymphatic 12. Allergic/Immunologic 13. Psych Psychiatric 14. Endo Endocrine Review of Systems Need at least 4, 10 for comprehensive 1. Eyes we got this one! 2. Constitutional How do you feel Fever Weight loss 3. ENT Problems with Ear, nose, throat, Sinus Deafness Dry mouth Congestion 4. CV Cardiovascular Problems with Heart or Circulation Heart Attack Chest Pain/ Angina Congestive Heart Failure Irregular Heart Beat High/Low Blood Pressure Pacemaker/defibrillator High cholesterol Review of Systems 5. Resp Respiratory Lung or Breathing problems Asthma / Emphysema Bronchitis / COPD / TB 6. GI Gastrointestinal problems with Stomach, liver or intestines Hepatitis/jaundice IBS / Chron s Constipation/Diarrhea 7. GU Genitourinary Kidney/Bladder reproductive problems Kidney stones Kidney failure 8. Integumentary (Skin) Problems with Skin Dermatitis Rosacea 9. Neurological Problems with your nervous system Headache / Migraine Numbness/tingling Weakness 10. Musculoskeletal Problems with your Muscles or Joints Arthritis: Osteo vs. Rheumatoid alan.peaslee@eyehealthpartners.com 12

13 Review of Systems 11. Hemato/lymphatic Problems with your Blood Anemia Clotting / Bleeding 11. Allergic/Immunologic Problems with Allergies or your immune system Allergies, hay fever Problems with immune system HIV Status 12. Psych Psychiatric Any mental health problems or concerns PTSD Depression /Anxiety Difficulty sleeping 14. Endo Endocrine any problems with your Hormones or Thyroid Increased urination/thirst Palpitations Hair loss Weight loss or weight gain Mental Status Mental Status What is todays date What day of the week What is the name of this place What is your phone number How old are you When were you born Who is the president of the united states? Who was the president before him? What was you mother s maiden name Count backward by 3 from 20 Mood and Affect Appropriate Happy / Sad Cooperative / Uncooperative Excited / Agitated Flat / Placid Vital Signs Systemic Vitals Height/Weight/BMI Blood pressure/pulse Respiratory Rate Temperature Automated vs. manual White coat Syndrome If you find it, you own it Ocular Vitals Vision Refractive State Pupils Visual Field EOM s IOP Functional Testing Diagnostic Testing alan.peaslee@eyehealthpartners.com 13

14 Ocular Vitals Vision Uncorrected/Corrected Distance/Near Pinhole Glasses/Contacts Lensometry Auto vs. Manual All Pairs The ones they wear The ones they complain about Refractive State Autorefraction Diagnostic Refraction Manifest Refraction Pinhole Pupils Size Symmetry Reaction Afferent Pupillary Defect Ocular Vitals Visual Field Confrontation Count Fingers See Fingers Amsler Grid Full Face field EOM s Pupil Reflex position Cover/Uncover Quantify IOP NCT Tonopen Icare Your number is your number Ocular Vitals Why does Doctor Repeat or recheck test It s particularly important for this patient It s very different than the last time or expected Quality of the response vs. Quantity A P S O.. Vs. A P S O Build confidence in your work Determine what we need to work on for training alan.peaslee@eyehealthpartners.com 14

15 Other Testing Functional Testing Color vision Ishihara HRR Stereo Muscle balance Sensory Motor Diagnostic Testing OCT Retina Optic nerve Anterior Seg Photography External Retinal Wide Angle Threshold fields Central Corneal Thickness (CTT) Topography Biometry Other Testing Functional Testing Color vision Ishihara HRR Red Cap Stereo Muscle balance Sensory Motor Diagnostic Testing OCT Retina Optic nerve Anterior Seg Photography External Retinal Wide Angle Diagnostic Testing Automated Fields SWAP Sita vs. Standard Fast vs. Standard Central Corneal Thickness (CTT) Pachymetry Topography Traditional Advanced Pentacam Galilei Biometry IOLMaster LenStar alan.peaslee@eyehealthpartners.com 15

16 Questions? CONTACT INFORMATION Diplomate, American Board of Optometry Center Director, VisionAmerica of Huntsville 1150 Eagletree Lane Huntsville, AL Office (256) ext Direct (256) Fax (256) Cell (229) Thank you! Diplomate, American Board of Optometry Office (256) ext Direct (256) Fax (256) Cell (229)

LECOM Health Ophthalmology

LECOM Health Ophthalmology Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable

More information

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) 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

More information

Medical History Form. Patient Information. Medical History. Middle Initial: Date: Salutation: Sex: First Name: Last Name: Current Address:

Medical History Form. Patient Information. Medical History. Middle Initial: Date: Salutation: Sex: First Name: Last Name: Current Address: Medical History Form Patient Information Salutation: Sex: Current Address: Email: Employer: First Name: Last Name: Middle Initial: Date: City: Zip Code: Phone 1: Phone 2: Date of Birth: Referral Source:

More information

Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC Patient Demographic Information

Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC Patient Demographic Information Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC 28470 Patient Demographic Information Account # Last Name: SSN: / / First: Middle: Marital Status: Single Married Separated Nickname:

More information

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please

More information

PATIENT HISTORY FORM

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

More information

Medical History Form

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

More information

Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6

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

More information

Thank you very much for choosing us and we look forward to your visit!

Thank you very much for choosing us and we look forward to your visit! Elizabeth Crandall, MD Ophthalmology 136 W. Cherry St Jesup, GA 31545 Phone: (912) 559-2467 Fax: (912) 559-2473 www.crandalleye.com Dear, Thank you for choosing us to provide you with your eye care needs.

More information

WELCOME TO OUR OFFICE

WELCOME TO OUR OFFICE WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment

More information

Patient History Form

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

More information

- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )

- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES ) NAME (Please Print) First Name M.I. Last Name DATE of BIRTH / / - YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES ) Exam Date:,20 PRESCRIPTIONS DRUGS Please Print MEDICATIONS NAMES ONLY NO PRESCRIPTION

More information

NEW PATIENT HEALTH HISTORY

NEW PATIENT HEALTH HISTORY NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records

More information

Medical Questionnaire

Medical Questionnaire Medical Questionnaire Date: Day Month Year Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in

More information

Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:

Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work: An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:

More information

Welcome to About Women by Women

Welcome to About Women by Women Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner

More information

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more

More information

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1 Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma

More information

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: 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

More information

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

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

More information

Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.

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

More information

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

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

More information

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 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 #

More information

Setting Your Sight Back on Life.

Setting Your Sight Back on Life. 8089 Callaghan @ IH10 210-342-1228 Patient Registration (Please Print)!!!!!!!!!!! Date: Name: DOB: Address:!! Street!!!!!! City!! State!! Zip Home Phone: Work Phone: Cellular: Occupation: Employer: Social

More information

Immediate Family History Please list Father, Mother, Brother, Sister or Children

Immediate Family History Please list Father, Mother, Brother, Sister or Children : Social Security # Name: of Birth: Age: Address: City: State: Zip: Home#: Cell#: Work#: E-mail: Status: Married Single Divorced Widowed Work Place/School: Occupation/Grade: Emergency Contact (Name/Phone):

More information

NEW PATIENT QUESTIONNAIRE

NEW PATIENT QUESTIONNAIRE Page1 Mala Bathija MD, PLLC 44000 West 12 Mile Road, Suite 212 Novi, MI 48377 14500 Northline Road Southgate,MI 48195 NEW PATIENT QUESTIONNAIRE Last Name First Name Phone # DOB Age Sex: M F Referring Physician

More information

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

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

More information

Health History Form Please Fill Out Entire Form

Health History Form Please Fill Out Entire Form Health History Form Please Fill Out Entire Form Name: Primary Physician: Referring Provider: Review of Symptoms: Check all that apply Date of Birth: Phone: Additional Concerns: Eyes: Blurry Vision Burning/Dryness

More information

medical questionnaire Date: Day Month Year

medical questionnaire Date: Day Month Year medical questionnaire Date: Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you

More information

Name: Date: Street Address: Referring Physician: How long have you had your current problem?

Name: Date: Street Address: Referring Physician: How long have you had your current problem? 3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:

More information

Salt Lake Orthopaedic Clinic Initial Visit Form

Salt Lake Orthopaedic Clinic Initial Visit Form Salt Lake Orthopaedic Clinic Initial Visit Form Name: Today s Date: Date of Birth: Age: Height: Weight: Handedness (R/L): Referring Physician: Primary Care Physician: Chief Complaint Why are you seeing

More information

WELCOME TO COPPELL VISION CENTER 541 E. Sandy Lake Road, Coppell, Texas (972) Personal Information

WELCOME TO COPPELL VISION CENTER 541 E. Sandy Lake Road, Coppell, Texas (972) Personal Information WELCOME TO COPPELL VISION CENTER 541 E. Sandy Lake Road, Coppell, Texas 75019 (972) 393-3937 (Please Print Clearly) Personal Information Last Name: First Name: Exam Date: / / Street Address: City/State/Zip:

More information

John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter

John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM PATIENT REGISTRATION FORM B S M R W A G KS MAC Z GR SO ZA L Please tell us about yourself so we can help you make the best decisions about your care. Date: Social Security #: E-mail: Name: MR / MRS / MS

More information

Creve Coeur Family Medicine, LLC

Creve Coeur Family Medicine, LLC Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal

More information

MCKAY UROLOGY LINCOLNTON OFFICE PATIENT HISTORY FORM

MCKAY UROLOGY LINCOLNTON OFFICE PATIENT HISTORY FORM Patient name: MRN #: Current Medications (prescription and over the counter medications including vitamins, herbs, aspirin, antacids, injectables, hormones and birth control medication) If you brought

More information

Mercy MS Center New Patient Information

Mercy MS Center New Patient Information Mercy MS Center New Patient Information Last Name: First Name: DOB: MULTIPLE SCLEROSIS HISTORY Reason for clinic visit: I have been diagnosed with MS or NMO (Date diagnosed ) I have not been diagnosed

More information

Wisconsin Integrative Pain Specialists

Wisconsin Integrative Pain Specialists Patient Information Today s Date: Patient s Name: DOB: Age: Gender: Marital Status: M S D What would you like us to call you? Address: City, State, Zip: Home Phone: Cell Phone: Work Phone: Email: Preferred

More information

Athens Rheumatology Clinic, LLC Sana Makhdumi, MD

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

More information

UnityPoint Clinic - Cardiology

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:

More information

Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?

Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit? ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT

More information

GIDEON G. LEWIS, M.D.

GIDEON G. LEWIS, M.D. GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed

More information

New Patient Intake Form

New Patient Intake Form 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

More information

NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE

NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-

More information

How to Code Correctly for E/M Services (1997 Guidelines)

How to Code Correctly for E/M Services (1997 Guidelines) How to Code Correctly for E/M Services (1997 Guidelines) Phillip Ward, DPM CPT Editorial Board Advisor for Foot and Ankle Former CPT Assistant Editorial Board Member Past President, APMA General Principles

More information

PATIENT INFORMATION FORM

PATIENT INFORMATION FORM PATIENT INFORMATION FORM Name: (First) (Middle) (Last) Birth Date: _ Social Security Number: _ Address: _Apartment #: City: State: Zip Code: Home#: Work# Cell#:_ Marital Status: Single Married Divorced

More information

MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014

MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014 MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014 Name: Date of Birth: Today s Date: Where did you get healthcare before? May we request records? Y N (requires signed release)

More information

PATIENT REGISTRATION INFORMATION. Please Print

PATIENT REGISTRATION INFORMATION. Please Print PATIENT REGISTRATION INFORMATION Please Print Dr. Mrs. Ms. Mr. First Name M.I. Last Sex: M F SS# Date of Birth / / Age Marital Status: Married Single Divorced Widowed If married, spouse s name: Mailing

More information

New Patient Information

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

More information

Patient Registration Form

Patient Registration Form Patient Registration Form Name: Today s Date: FIRST MIDDLE LAST Home Address: City: State: Zip: Telephone: ( ) Birthdate: Age: Occupation: SSN: Employer: Years There: Employer s Address: City: State: Zip:

More information

New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:

New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax: New Patient Packet Patient Name: DOB: Age: Sex: Male / Female Height: Weight: PHYSICIAN CARE Primary Care Physician: Address: City: State: Zip: Phone: Fax: Referring Physician (if different from PCP):

More information

* CC* PATIENT QUESTIONNAIRE

* CC* PATIENT QUESTIONNAIRE Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please

More information

Modesto Gastroenterology Medical Corporation

Modesto Gastroenterology Medical Corporation Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298

More information

Dear Mercy Cancer Center Radiation Oncology Patient

Dear Mercy Cancer Center Radiation Oncology Patient Dear Mercy Cancer Center Radiation Oncology Patient Welcome to our Department. In order to complete our records, and enable our physicians to ensure that your questions are fully addressed, we appreciate

More information

SPINE AND ORTHOPEDIC PAIN CENTER, P.C. WINIFRED D. BRAGG, M.D.

SPINE AND ORTHOPEDIC PAIN CENTER, P.C. WINIFRED D. BRAGG, M.D. SPINE AND ORTHOPEDIC PAIN CENTER, P.C. WINIFRED D. BRAGG, M.D. PATIENT INFORMATION Patient Name (Last, First, Middle Initial) Home Address Gender (M/F) Phone (Home) City State Zip code Phone (Work) Marital

More information

Pre-Admission Testing Questionnaire

Pre-Admission Testing Questionnaire Pre-Admission Testing Questionnaire Approximately 2 weeks prior to your surgery date you will receive a telephone call from our Pre-Admission Testing department. During this conversation, a Registered

More information

MEDICAL HISTORY QUESTIONNAIRE

MEDICAL HISTORY QUESTIONNAIRE MEDICAL HISTORY QUESTIONNAIRE Name Birth Date Name of doctor referring you Doctor Phone Doctor Address Date of last eye exam REVIEW OF SYSTEMS Do you currently have any problems in the following areas?

More information

Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:

Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation: Date: / / Patient s Name: Address: Preferred Home: ( ) - Work: ( ) - Cell: ( ) - Text Message Reminders : Yes No Social Security #: Date of Birth: - - / / For ADULT Patients : Employer: Occupation: Spouse

More information

DNA CENTER New Patient Information

DNA CENTER New Patient Information DNA CENTER New Patient Information Name Email: Address City State Zip Home Phone Work Cell Phone Social Security Number Date of birth Gender ( Male/Female) Age Please Circle: Hispanic/Latin or Non Hispanic/Latin

More information

Preferred Name: First Name: Last Name: Middle Initial: Mailing Address: City: State: Zip: Alternate number: address:

Preferred Name: First Name: Last Name: Middle Initial: Mailing Address: City: State: Zip: Alternate number:  address: Welcome to our office! We want to provide you with the very best in vision care. In order for us to serve you better, we need certain biographical information from you. Please complete the following data

More information

Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C

Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Interventional Pain Medicine P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Gainesville Braselton Medical Park 1, Suite 300 Medical Plaza B, Suite 402 1315 Jesse Jewell Parkway 1404 River

More information

Morris Medical Center, P.A.

Morris Medical Center, P.A. Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~

More information

Southern Maine Integrative Health Center Adult Intake Form

Southern Maine Integrative Health Center Adult Intake Form Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:

More information

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury

More information

Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire

Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed

More information

Amarillo Surgical Group Doctor: Date:

Amarillo Surgical Group Doctor: Date: Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:

More information

Retinal Consultants of San Antonio PATIENT REGISTRATION

Retinal Consultants of San Antonio PATIENT REGISTRATION PATIENT REGISTRATION Today s Date Referred by Patient Full Name Home Address City State Zip Code Home Phone Cell Phone E-mail address Date of Birth Preferred Method of Contact: Home Phone / Cell Phone

More information

Ophthalmology. Caring For Your Eyes. Jurong Medical Centre

Ophthalmology. Caring For Your Eyes. Jurong Medical Centre Ophthalmology Caring For Your Eyes Jurong Medical Centre Your eyes and you At Jurong Medical Centre, we have a dedicated team of ophthalmologists that specialise in treating a wide range of acute and chronic

More information

Medical History Form

Medical History Form General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:

More information

Richard Senysyzn, MD Psychiatry for Adults 1260 River Acres Drive New Braunfels, TX , Fax. (888)

Richard Senysyzn, MD Psychiatry for Adults 1260 River Acres Drive New Braunfels, TX , Fax. (888) ADHD Evaluation Intake Form Patient Contact Information Patient Name: Date of Birth: Age: Last First MI Address: Email address: Contact phone number: Emergency Contact/Number/Relationship: Pharmacy: Primary

More information

PATIENT DEMOGRAPHIC SHEET

PATIENT DEMOGRAPHIC SHEET PATIENT DEMOGRAPHIC SHEET Name: Date: Occupation: Gender: Marital Status: Date of Birth: SSN: HOME Street: City: State: Zip: Phone: Cell: Emergency contact : E-Mail Address WORK / SCHOOL Street: City:

More information

Welcome. Medical History Do you have any allergies to medications? No Yes If Yes, Please Explain

Welcome. Medical History Do you have any allergies to medications? No Yes If Yes, Please Explain Welcome Name: Address: City: State: Zip: Employer: Occupation: Birthdate: / / Social Security #: - - Name of Primary Care Physician: Guardian (If Applicable): Today s Date: / / Cell Phone: - - Home Phone:

More information

Room # Critical Care & Pulmonary Consultants, P.C.

Room # Critical Care & Pulmonary Consultants, P.C. Room # Critical Care & Pulmonary Consultants, P.C. Health History You have been scheduled for an appointment with Critical Care and Pulmonary Consultants, P.C. This health history will help us facilitate

More information

Inner Balance Acupuncture

Inner Balance Acupuncture Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:

More information

Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency

Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.

More information

EDWARD M STROH MD PC RETINA New Patient Packet

EDWARD M STROH MD PC RETINA New Patient Packet EDWARD M STROH MD PC RETINA New Patient Packet PATIENT INFORMATION First Name Middle Last Birth Date / / Age Gender: MALE FEMALE Street Address City State Zip Home Phone Employer Cell Phone Other Phone

More information

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

PULMONARY MEDICINE PATIENT QUESTIONNAIRE PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical

More information

CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)

CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425) IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:

More information

Psychiatric Evaluation Intake Form

Psychiatric Evaluation Intake Form Patient Contact Information Psychiatric Evaluation Intake Form Patient Name: Date of Birth: Age: Last First MI Address: Contact phone number: Email address: Emergency Contact/Number/Relationship: Primary

More information

DATE OF BIRTH: MELANOMA INTAKE

DATE OF BIRTH: MELANOMA INTAKE MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other

More information

Past Medical History. Chief Complaint: Appointment Date: Page 1

Past Medical History. Chief Complaint: Appointment Date: Page 1 Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty

More information

New Patient Specialty Intake Form Department of Surgery

New Patient Specialty Intake Form Department of Surgery This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient

More information

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email

More information

LAKES INTERNAL MEDICINE

LAKES INTERNAL MEDICINE LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education

More information

GoPrivateMD General Information & History

GoPrivateMD General Information & History Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.

More information

Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:

Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code: Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business

More information

Thoracic Cardiovascular Institute

Thoracic Cardiovascular Institute Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Thoracic Cardiovascular Institute PATIENT HISTORY FORM Please

More information

Welcome to the Kentucky Neuroscience Institute at the University of Kentucky!

Welcome to the Kentucky Neuroscience Institute at the University of Kentucky! Welcome to the Kentucky Neuroscience Institute at the University of Kentucky! The Kentucky Neuroscience Institute is on the first floor of the Kentucky Clinic. The address is 740 South Limestone Street,

More information

DEPARTMENT OF NEUROSURGERY Spine Center New Patient Intake Form

DEPARTMENT OF NEUROSURGERY Spine Center New Patient Intake Form DEPARTMENT OF NEUROSURGERY Spine Center New Patient Intake Form Today's date: Your name: Date of birth: Email address: CHIEF COMPLAINT What is the main reason that you are seeking medical attention? Please

More information

Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).

Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning

More information

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

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

More information

OhioHealth Orthopedic & Sports Medicine Physicians

OhioHealth Orthopedic & Sports Medicine Physicians Page 1 of 6 OhioHealth Orthopedic & Sports Medicine Physicians 335 Glessner Avenue, Mansfield, Ohio 44903 PATIENT INTAKE ASSESSMENT OFFICE USE ONLY Fax to: OR Control 419-520-2831 For Joint Replacement

More information

SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD

SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD Name: Height: Birthdate: Weight: Chief Complaint: What is the reason for your appointment? (please describe why you are here) Medications: Please list ALL medications with dosages you are currently taking,

More information

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please

More information

George M. Salib, M.D., Inc.

George M. Salib, M.D., Inc. George M. Salib, M.D., Inc. Patient Acknowledgement Regarding Precautions Following Dilation It may be necessary to dilate your eyes during your eye examination or treatment. Dilation results in light

More information

Please fill out this form as completely as possible. This information will determine how we treat your pain problem.

Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Name Date of birth Age Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your

More information

New Patient Questionnaire Pediatric Orthopaedic Surgery

New Patient Questionnaire Pediatric Orthopaedic Surgery Page 1 of 5 New Patient Questionnaire Pediatric Orthopaedic Surgery First Name: Last Name: Middle: DOB: Height: Weight: Primary Care Physician/Pediatrician Name: Address: Phone Number: Chief Compliant

More information

HD CLINIC MEDICAL HISTORY FORM

HD CLINIC MEDICAL HISTORY FORM HD CLINIC MEDICAL HISTORY FORM Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the questions below as best as you can. If you need assistance, a caregiver/companion

More information

PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT

PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction

More information

Patient Information: Date: Last Name: Street Address: City: SS #: First Name: Sex: M F Birthdate: Contact Information:

Patient Information: Date: Last Name: Street Address: City: SS #: First Name:   Sex: M F Birthdate: Contact Information: Welcome to PHC Family Medicine! We know you have a choice and appreciate your choosing us to provide care to your family. Dr. Frankhouser will be asking about your concerns today, but so that we can learn

More information