Name of Pa. tient: Last. First. per day) 50 mg. X-ray dye or. IV contract. Name (Last) (First) Address. City, state/ zip code
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1 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 Name of Pa tient: Last _ First MI Date of Birth: Age: Sex: M F Date of visit: Height: Weight lbs. What medical problem or condition are you here to have evaluated? Current Medications: (Please list all prescription, non-prescription medications and nutritional supplements) Current Medications Example: Lopressor Dose (Strength) 50 mg Schedulee (How many & times per day) 1 tablet, two times a dayy How long? 6 months Drug/ Food allergies: Please list all allergies to medications and other substances Are you allergic to: Yes Describe reactions they cause Any medications Iodine, fish, shellfish X-ray dye or IV contract Can you take aspirin? Who is your primary care physician (PCP)?? Name (Last) (First) Address Office phonee number Office fax number City, state/ zip code
2 Coronary artery disease risk factor history Do you have? Yes High blood pressure Diabetes Controlled with Insulin, how long Pill Diet High cholesterol Family history of heart or vascular disease A history of Rheumatic fever or Scarlet fever Social history Do you now or have you ever smoked tobacco products? Cigarettes. # Of packs per day # of years Cigars: Pipes When was your last cigarette, cigar or pipe? Do you? Drink alcohol on a regular basis? Yes If no. did you drink heavily in the past? Yes If yes, how much do you typically drink in one week? Do you use recreational drugs? Have you ever been treated for substance abuse? Diet: Balanced Low fat cholesterol Low salt special diet Other, please describe Activity level: which of the following best describes your level of physical activity both in your daily life and you leisure time Exercise strenuously on a regular basis Exercise moderately on a regular basis Exercise on an occasional basis Do not regularly exercise, but have an active lifestyle Have difficulty accomplishing light chores or daily living Require assistance to accomplish self care
3 Have you ever had any of the following: Exam by a cardiologist (Heart doctor) Heart Catheterization or angiogram Coronary angioplasty (PTCA/Balloon/stents) Exercise stress test (Treadmill) Echocardiogram (Ultrasound of the Heart) Open heart surgery Pace maker/defibrillator Yes Date or year Place (Hospital or city) Complications/problems Previous operations/procedures Year Surgeon Place (Hospital or City) Complications/Problems Reasons for other Hospitalizations (n surgical Admissions) Year Physician Place (Hospital or City) Please list any other medical illness, any other history of cancer or chronic conditions How long have you had this If you are scheduled for surgery or a hospital stay, please answer the following question: Have you or a blood relative had any problems with anesthesia Yes If yes, please describe
4 SKIN EAR/NOSE/THROAT KIDNEYS/URINARY TRACT Rashes, psoriasis or dermatitis Loss of hearing Kidney disease or failure n healing sores or skin ulcerations Hearing aids? Yes History of Kidney dialysis Ringing in the ears what year: EYES Frequent or severe nose bleeds Kidney stones or infection wear glasses Frequent sinus infections Pain or burning with urination wear contact lenses Dentures Dribbling or incontinence Permanent blindness in either eye Multiple trips to bathroom to Cataracts NERVOUS SYSTEM urinate at night Glaucoma Frequent headaches or migraines Blood in urine during past yr Epilepsy or seizures Enlarged prostate HEART Date of last seizure: Heart Attack, what year: Depression METABOLISM/ENDOCRINE Chest Discomfort/angina Nervous disorder Thyroid disorder with physical activity specify: Gout Chest Discomfort/angina at rest Recent weight gain or loss(>10lbs) Shortness of breath with exertion CIRCULATION Shortness of breath at rest Discoloration of feet or legs MUSCLES/BONES/JOINTS Require more than one pillow at night Pain in legs or buttocks with exercise Arthritis or other joint disease to breathe well Sores or ulcers on feet or legs Chronic back trouble Heart failure or fluid on lungs Blood clot in artery Curvature of the spine (scoliosis) Palpitations, racing or pounding Blood clot in leg vein heart beat Ankle or leg swelling REPRODUCTIVE (For Women) Pauses in the heart beat Phlebitis of leg veins Are you or might you be pregnant? Previously diagnosed heart rhythm Sudden visual disturbances in either Yes disturbance eye Date(or year) of last period Heart murmur Weakness or paralysis of one side of Mitral valve prolapsed the body REPRODUCTIVE (for men) BLOOD Temporary speech loss or difficulty Have you had a vasectomy? Bleeding or bruising tendency talking Yes Previous blood transfusion Stroke Erectile Dysfunction? Blood disorder Dizziness, light headedness or Yes Specify: black out spells Recent fever Aneurysm of any blood vessels History of hepatitis or other Mini strokes or TIA s communicable disease STOMACH/INTESTINES LUNGS Dark, tarry stools Asthma or wheezing Coughing up blood Chronic constipation Recent bronchitis or chest cold Exposure to asbestos Stomach ulcer or peptic ulcer Pneumonia Blood clot(embolus) to lungs Frequent heartburn or indigestion Emphysema Liver disease or jaundice Tuberculosis what year: Chronic Cough Frequent Diarrhea
5 Family History Relation Age Age at death Cardiac history Father Mother Sister Sister Brother Brother Please list which family members (blood relatives) have experienced these conditions: Heart attack Age Aneurysm: Age Diabetes: Age Cancer: Sudden death Age High blood pressure Age High cholesterol Age Heart failure Stroke Age Arteriosclerosis (Hardening of the arteries) Age Do you have any other special concerns or additional information we should be aware of regarding your care: 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 Patient signature Date
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DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
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
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM
PATIENT MEDICAL HISTORY FORM Name: Date: Social Security #: DOB: Height: Weight: Email: Primary Care Physician: Referred by: Pharmacy Name/Location/Phone Number: Dialysis Center and Phone Number (if applicable):
Phone (573) * Fax (573) PATIENT HISTORY FORM. Name Date of Birth M/F. Reason for Appointment Height
Phone (573) 256-7700 * Fax (573) 256-3003 PATIENT HISTORY FORM Name Date of Birth M/F Date and Time of Appointment Referring Physician Preferred Pharmacy Reason for Appointment Height PHYSICIANS (Please
Cooper Neurological Institute Phone: Fax:
Cooper Neurological Institute Phone: 856-968-7965 Fax: 856-968-8697 PATIENT INFORMATION AND HEALTH HISTORY Name: Date: Birth date: Age: Home Phone: Cell Phone: If patient is a minor or disabled, please