New Patient Medical Questionnaire DATE:
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- Clemence Nelson
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1 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 you here for today? CARDIAC PROBLEM LIST Please check any of the following disorders that you HAVE or HAVE HAD, and indicate the year it was first identified. CARDIAC: No Angina (heart pain) _ No Heart Attack _ No Abnormal Heart Valve(s) _ No Coronary Artery Disease _ No Mitral Valve Prolapse No Heart Failure _ No Cardiomyopathy _ No Pericarditis No Cardiomegaly (Enlarged Heart) No Rheumatic Fever No Heart Murmur VASCULAR: _ No Pacemaker No Implantable Defibrillator No Arrhythmia / Abnormal Rhythm No Stroke or TIA (mini-stroke) No Pulmonary Embolism (clots in lungs) No Renal(kidney) Artery Disease No Peripheral(leg or arm)artery Disease No Other type of Vascular Disease No DVT (clots in leg) No History of aneurysm 1
2 New Patient Medical Questionnaire DATE: Patient Name: DOB: AGE: CURRENT MEDICATIONS / SUPPLEMENTS No Please list ALL medications that you are taking at home. Include ALL prescription medications, non-prescription medications, vitamins, herbal remedies and supplements Name of Medication Example Lasix 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) (Please attach additional pages if necessary) Dose/Strength How 40 mg Many/How Often/When twice a day - morning and night ALLERGIES / INTOLERANCES TO MEDICATIONS No Please list any medications, foods, or materials such as contrast dye or iodine that you are allergic to, had an adverse reaction to or do not tolerate and describe the reaction. Medication Reaction (e.g. hives, swelling, short of breath, rash, etc.) Reviewed By: 2
3 New Patient Medical Questionnaire DATE: Patient Name: DOB: AGE: PAST MEDICAL HISTORY Please check any of the following disorders that you HAVE or HAVE HAD, and indicate the year it was first identified PULMONARY: No Asthma No Emphysema / COPD_ No Pneumonia GASTROINTESTINAL: No Reflux (GERD)_ No Diverticulosis / Diverticulitis No Liver Disease / Hepatitis_ No Gallbladder Disease / Gallstones RENAL/GENITOURINARY No Dialysis No Kidney Stones_ NEUROLOGICAL / PSYCHOLOGICAL: No Intracranial (in the brain) Bleeding No Migraine Headaches No Depression FEMALE REPRODUCTIVE: Not Applicable No Multiple Miscarriages_ No Menopause (at what age?) No Bronchitis No Tuberculosis No Sleep Apnea No Hiatal Hernia_ No Ulcers No Gastritis No Gastrointestinal Bleed_ No Prostate Disease No Kidney Disease /Elevated Creatinine No Seizure Disorder No Dementia_ No Anxiety Disorder No Currently Pregnant (# of weeks) _ ENDOCRINE: No Thyroid Disorder No Adrenal Disorder OTHER: No Anemia No Bleeding Disorder_ No Clotting Disorder No Gout _ No Ambulate with assistance No HIV No Vertigo No Cancer (type?)_ No Autoimmune Disorders (i.e.lupus) Please list any other health problems that are not on the list: No Osteoporosis Arthritis No Rheumatoid Arthritis No Previous weight loss meds (i.e. Fen Phen)_ 3
4 SURGICAL HISTORY / OPERATIONS No Please list any surgeries you have had and include the year and location. Surgery Date Surgeon Location Example: Gallbladder Removed 1980 Dr. Frank Smith Parkland, Dallas SOCIAL HISTORY: Marital Status?: Single Married Divorced Separated Widowed Domestic Partner Previously Widowed- Number of sons?:_ Number of daughters?: Current hometown? With whom do you live? Do you have a Medical Power of Attorney? No Who? Advanced Directives? None Do Not Resuscitate Healthcare Proxy Living Will Date: Are you retired?: No Current or Previous Occupation: Leisure activities?: (Include any hobbies)_ Home exercise equipment? No If yes, what types_ Home blood pressure monitor? No If yes, average readings: 4
5 Do you use tobacco? Formerly Never Type: How much: Start/Quit Dates Cigarettes _ per day Years Smoked?_ Quit Date? Cigars _ per day Years Smoked?_ Quit Date? Pipes _ per day Years Smoked?_ Quit Date? Chewing tobacco _ per day Years Used? Quit Date? Do you use alcohol? Formerly Never Describe your use? Rarely Social Daily Frequently Occasional Quit (when)_ Type: How much: Beer _ cans per day / wk / mo / Wine _ glasses per day / wk / mo / yr Spirits _ glasses per day / wk / mo / yr Do you use caffeine? Formerly Never Type: Caffeinated Coffee? cups per day / wk / mo / yr Quit (when) Caffeinated Tea? cups per day / wk / mo / yr Quit (when) Caffeinated Soda? cans per day / wk / mo / yr Quit (when) Chocolate? servings per day / wk / mo / yr Quit (when) Do you use recreational drugs? Formerly Never Type: How much: Start/Quit Dates Marijuana per day wk mo yr When did you start? Quit? Rehab? Cocaine per day wk mo yr When did you start? Quit? Rehab? Methamphetamine per day wk mo yr When did you start? Quit? Rehab? Exercise No/Sedentary Occasional Regular Active Lifestyle Physically unable to exercise 5
6 FAMILY HISTORY: Please indicate below if you Father, Mother or Sibling(s) have or have had the following diagnoses by providing the age when it was diagnosed. Cancer: Hypertension: Diabetes: Cholesterol: Heart Failure / Cardiomyopathy: Stroke: Blood Clots: Aneurysm-: UNKNOWN NONE _ Were You Adopted? No Reviewed By: 6
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Today s Date North Georgia Urology Center, P.C. Urology Patient Questionnaire Dear Patients: to help the urologist give you better care, please take a moment of valuable time to answer the following questions.
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
Name: (Last) (First) (Middle) Address: (City) (State) (Zip) Home: ( ) Work: ( ) Cell: ( ) Age: DOB: SS#: Height: Weight: Occupation:
2124 Route 35, Tel: (732) 788-0349 Holmdel, Fax: (877) 211-6276 NJ, E-mail: info@gramercypaincenter.com 07733. www.gramercypaincenter.com Date: Name: (Last) (First) (Middle) Home: ( ) Work: ( ) Cell: (
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
MEDICAL HISTORY FORM FOR FOLLOW-UP
MEDICAL HISTORY FORM FOR FOLLOW-UP ID NUMBER: 0a) Date of Collection / / 0b) Staff Code Instructions: Whenever numerical responses are required, enter the number so that the last digit appears in the rightmost