ANY FAMILY HISTORY OF ANEURYSM OR DVT?
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- Terence Carroll
- 6 years ago
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1 NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) HOW MUCH ALCOHOL DO YOU DRINK APPROXIMATELY? DAY WEEK MONTH DO YOU SMOKE? HAVE YOU EVER SMOKED? WHEN DID YOU STOP? ILLEGAL DRUG USE? PAST/ PRESENT/ NONE OCCUPATION (CURRENTLY/ BEFORE RETIRED) LIST YOUR FAMILY MEDICAL PROBLEMS: CIRCLE ONE: AGE(S) NOW/ AT MAJOR ILLNESS/CAUSE TIME OF DEATH: OF DEATH: MOTHER: LIVING / DECEASED FATHER: LIVING / DECEASED SIBILINGS: LIVING / DECEASED CHILDREN: LIVING / DECEASED ANY FAMILY HISTORY OF ANEURYSM OR DVT? Page 1 of 6
2 HAVE YOU EVER HAD ANY OF THE FOLLOWING LISTED BELOW IN THE PAST? VASCULAR: Aneurysm Deep Vein Thrombosis (DVT) Pulmonary Embolus Carotid Disease Leg Swelling Varicose Veins Spider Veins Treatment of Varicose Veins Gangrene Stroke Vascular Problems CARDIAC: Heart Problems Heart Attack High Cholesterol Pacemaker Automatic Defibrillator Rhythm Problems High Blood Pressure Heart Murmur PULMONARY: Asthma Bronchitis COPD (Emphysema) Lung Cancer Pneumonia Sleep Apnea GASTROINTESTINAL: Bleeding Hepatitis Reflux Gallbladder Disease Colon Polyps Inflammatory Bowel Ulcer Irritable Bowel Disease GU: Prostate Cancer Kidney Stones Kidney Failure BPH Page 2 of 6
3 ENDOCRINE: Gout Overactive Thyroid Underactive Thyroid Diabetes GYN: Cervical Cancer Hysterectomy NEUROLOGIC: Stroke Mini-Stroke or TIA Arm or Leg Weakness Episode of loss of vision Difficulty Speaking Sciatica Fainting spells Seizures Back injury Headaches MUSCULOSKELETAL: Osteoporosis Rheumatoid/Inflammatory Arthritis Osteoarthritis History of fracture Fibromyalgia Polymyalgia Rheumatic (PMR) BLOOD PROBLEMS AND BLEEDING: Do you heal cuts slowly Anemia WHEN? Blood Disorder Excessive bleeding in surgery Abnormal bruising or bleeding due to blood thinner meds Phlebitis or blood clots in veins INTEGUMENTARY (SKIN DISORDERS)/AUTO IMMUNE - Circle one below: Rashes, Eczema, Psoriasis Melanoma Lupus, Scleroderma, Sjogrens Basal Cell/Squamous Cell PSYCHIATRIC: Anxiety Depression Suicidal Ideation Page 3 of 6
4 OTHER: Cataracts Glaucoma WHAT MEDICATIONS ARE YOU ALLERGIC TO? ARE YOU ON A BLOOD THINNER? DO YOU TAKE A STATIN? DO YOU TAKE COUMADIN? DO YOU TAKE PREDNISONE? DO YOU TAKE ASPIRIN? DO YOU TAKE PLAVIX? NAMES & DOSE OF KNOWN MEDICATIONS: RECENT SYMPTOMS IN THE LAST 6 MONTHS? Fever/Chills Weight change in the past 6 months Fatigue? ARE YOU PREGNANT? ARE YOU ON BIRTH CONTROL? Impaired Hearing Dizziness Temporary spells of blindness Double Vision NEUROLOGIC: Arm or Leg Weakness or Paralysis Difficulty Speaking Loss of vision in one eye Poor balance Headaches Sciatica Fainting spells Seizures Back injury NEUROPATHY: Numbness in legs Pins and Needles Hands Pins and Needles Feet Page 4 of 6
5 CARDIOVASCULAR: Chest pain in past 6 months Angina in past 6 months Shortness of breath with walking Shortness of breath lying down Heart failure Irregular heartbeat RESPIRATORY: Spitting up blood Chronic or frequent cough Shortness of breath Chest congestion Recent upper respiratory infection Recent flu symptoms Wheezing Sleep Apnea VASCULAR: Swelling of feet or legs Leg pain with walking Pain in feet at night Wounds on legs/feet Varicose Veins Skin color change Gangrene SKIN: Itching Rashes Wound Lesions GASTROINTESTINAL: Stomach ulcer Vomiting blood Hiatus hernia Heartburn or Indigestion Gallbladder disease Liver trouble Black stools Recent change in bowel movements Bleeding with bowel movements Hemorrhoids Frequent diarrhea Abdominal Pain GENITO-URINARY: Pain on urination Impotence Frequent Urination Blood in urine now Frequent urinary tract infection Night time urination MUSCULOSKELETAL: Muscle Weakness Page 5 of 6
6 Pain Joint Stiffness Joint Swelling Boney Aches HEMATOLOGIC: Anemia Blood disorder Cancer ENDOCRINE: Treatment of thyroids Diabetes PSYCHIATRIC: Depression Anxiety PATIENT SIGNATURE: DATE: Page 6 of 6
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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
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
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
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