Surveillance Questionnaire
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- Austen Harvey
- 6 years ago
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1 Surveillance Questionnaire 1. Have you ever had the following health conditions? If yes, please note when the health condition started or occurred, type of treatment, and any limitations (e.g. heart attack in 2000, see cardiologist regularly, normal stress test, no limitations). Yes No Health condition If yes, please provide more details. Color blindness Cataracts or glaucoma Other eye or vision problems Hearing loss Meniere s disease Chronic sinus problems Nasal polyps Other ears, nose or throat problems High blood pressure Heart murmur Heart disease Angioplasty or stent placement Angina Heart attack Heart surgery Heart failure Heart arrhythmia (e.g. atrial fibrillation) Pacemaker or defibrillator Stroke or mini-stroke (TIA) Peripheral vascular disease Other heart or blood vessel problems Asthma Pneumonia Bronchitis Emphysema COPD Tuberculosis Asbestosis Silicosis Other lung or breathing problems Kidney stones Kidney disease Kidney failure (including dialysis) Hepatitis Liver failure Other kidney or liver problems 1
2 Yes No Health condition If yes, please provide more details. Ulcer Gallstones or gallbladder disease Crohn s disease or ulcerative colitis Celiac disease Pancreatic disease Other digestive system problems Arthritis Tendonitis Chronic neck or back pain Other bone, joint, or muscle problems Eczema Other skin condition Migraines or other chronic headaches Brain tumor Seizures or epilepsy Cerebral palsy Parkinson s disease Multiple sclerosis Neuromuscular disease Carpal tunnel syndrome Peripheral neuropathy Other brain or nerve problems Claustrophobia (fear of confined spaces) Depression Anxiety or panic attacks Other phobias or mental health issues Use of illegal substance (e.g. cocaine, heroine, LSD, recreational marijuana) Alcoholism Abuse of prescription drugs Other chemical dependency problems Diabetes High cholesterol Thyroid problems Other gland problems (adrenal, pituitary, pancreas, parathyroid, ovary, testicle) Gout Other metabolic or endocrine problems Anemia (low hemoglobin) Leukemia or lymphoma Blood clots Hemophilia Other blood disorder 2
3 Yes No Health condition If yes, please provide more details. Skin cancer Other cancers Rheumatoid arthritis Radiation therapy Chemotherapy Transplant recipient Chronic use of steroids (e.g. prednisone) Other immune system problems Cold-related problems (e.g. frostbite) Heat-related problems (e.g. heat stroke) Metal objects in body (e.g. shrapnel, surgical plates or screws) FEMALE ONLY Menstrual disorder Infertility Miscarriage Lump on breast Other female specific problems MALE ONLY Impotence Infertility Decreased or abnormal sperm Lump on testicle Other male specific problems Any other health problems Please answer the following questions. Yes No 2. Have you ever had any surgeries? If yes, what type and when? 3. Have you ever spent the night in a hospital? If yes, what for and when? 4. Do you currently take any prescription or over-the-counter medications? If yes, list all medications and dose (if known): 3
4 5. Are you allergic to any of the following? If yes, list what you are specifically allergic to and what happens (e.g. strawberries cause tongue to swell). Yes No Allergens If yes, please provide more details. Food (e.g. peanuts, strawberries) Animals (e.g. cats, dogs) Outdoor environment (e.g. pollen, grass) Insects (e.g. bees, spiders) Medications (e.g. penicillin, lisinopril) Latex (e.g. gloves) Chemicals (e.g. pepper spray, isocyanates) Metals (e.g. nickel) Other 6. In the last year, have you had any of the following symptoms or problems? Yes No Symptom Yes No Symptom Unplanned weight loss Persistent open sores Fever, chills, sweating Joint pain, swelling, or stiffness Fainting or passing out Neck pain Frequent headaches Back pain Loss of vision in one or both eyes Arm, elbow, wrist, or hand pain Wear contacts or glasses Difficulty moving arms or legs Ringing in the ears Poor or absent sense of smell Frequent nose bleeds Poor or absent sense of taste Difficulty swallowing Weakness Chest pain Numbness or tingling Shortness of breath Balance problems Palpitations Dizziness Leg cramps with walking or exercise Tremor Swollen ankles Memory or speech problems Wheezing Panic attacks Difficulty using respiratory protection equipment Thoughts of hurting yourself Cough lasting longer than 3 weeks Thoughts of hurting others Coughing up blood Cannot tolerate cold temperatures Stomach pain Cannot tolerate hot temperatures Dark or bloody stools Tired most of the time Frequent diarrhea Excessive thirst and urination Frequent constipation Prolonged or excessive bleeding Blood in urine Spontaneous bleeding Jaundice (yellowing of eyes or skin) WOMEN ONLY - excessive or Sensitive skin irregular menstrual bleeding If yes to any of the above, please explain here: 4
5 7. List the last 5 jobs that you have had, starting with your current or most recent job. 8. Have you ever worked in any of the following industries? If yes, note for how many months or years next to the industry. Yes No Industry Yes No Industry Battery manufacturing Plastic manufacturing Car body repair Pottery Chemical plant Printing Cotton, flax, or hemp manufacturing Pulp or paper mill Farming Quarrying Foundry Rubber manufacturing Glass manufacturing Sand blasting Logging Stone cutting Meatpacking Textiles Mining Trucking Oil refinery Welding 9. Have you ever been exposed to the following items at work? If yes, note for how many months or years next to the exposure. Yes No Exposures Yes No Exposures Arsenic Loud noise Asbestos Mercury Cutting oils Paints Fiberglass Pesticides Formaldehyde Pneumatic tools Herbicides Radioactive materials Insecticides Rock wool Isocyanates Silica Lacquers Solvents Lasers Ultraviolet radiation Lead Vibrating tools 5
6 Please answer the following questions. Yes No 10. Do you feel you have any health problems as a result of your current or previous jobs? If yes, please describe: 11. Do you feel you need any accommodations in order to do this job? If yes, please describe: 12. Do you currently use tobacco? If yes, for how many years? What type(s)? Cigarettes Cigars or pipe Snuff or chewing tobacco e-cigarettes If cigarettes, how many packs per day? 13. Did you formerly use tobacco? If yes, for how many years before quitting? What type(s)? Cigarettes Cigars or pipe Snuff or chewing tobacco e-cigarettes If cigarettes, how many packs per day? 14. Do you currently drink alcohol? If yes, how many times do you drink per week? How many drinks do you usually have at a time? 15. Did you formerly drink alcohol? If yes, how many times did you drink per week? How many drinks did you usually have at a time? 16. Do you have any hobbies? If yes, what hobbies? I certify that the information provided by me in this questionnaire is complete and true to the best of my knowledge. Name: Signature: Date: 6
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Allina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History
Medical Questionnaire
MEDICIS Health Testing Center Avenue de Tervueren 236 115 Bruxelles Tel : 2/762.5.44 Medical Questionnaire Name :. Maiden name : First name :. Sex :. Address :...... Phone (private) : Office :. Date of
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
Health History. Personal Health History. Institute of Complementary Medicine. FOC Health History - ICM
Reason for office visit today FOC Health History - ICM Health History Whom may we thank for referring you today? Do you have another primary care provider? Date of last physical exam Previous or referring
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
Cell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
PATIENT HISTORY FORM
PATIENT HISTORY FORM Date: Page 1 of 5 Last Name: First Name: Middle Initial: Referred By: Age: Primary Care Doctor: Please provide name(s) of other physician(s) that you have visited within the last year: