WASHINGTON UNIVERSITY SCHOOL OF MEDICINE. Cranial Health History Form
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- Dominic Fletcher
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1 WASHINGTON UNIVERSITY SCHOOL OF MEDICINE Cranial Health History Form Welcome to the Neurosurgery Department at Washington University. To help us treat you, please fill this form out completely. Your Name: Today s Date: Your date of birth: Your age: Are you: right-handed left-handed ambidextrous Who referred you to us: Who is your primary care physician? If same as referring, check here: List any physicians you would like us to send our notes to: What problem are we seeing you for today: Past Medical History Neurological problems: YES NO TIA (transient ischemic attack) Stroke Brain bleed (intracerebral hemorrhage) Brain aneurysm Brain vascular malformation (AVM, cavernous malformation) Brain tumor (brain neoplasm Narrowing of carotid arteries (carotid artery stenosis) Seizures (convulsions) Dementia/Alzheimer s Disease Cervical disc disease Cervical stenosis Lumbar disc disease Lumbar stenosis Heart problems: Chest pain (angina, coronary artery disease) Heart Attack (myocardial infarction) Congestive Heart Failure High blood pressure (hypertension) Aortic insufficiency Mitral valve regurgitation Atrial fibrillation Mitral valve prolapse Page 1 of 5
2 Lung problems: YES NO Emphysema (COPD) Asthma Tuberculosis Endocrine problem: High thyroid levels (hyperthyroidism) Low thyroid levels (hypothyroidism) Diabetes GI problems (stomach, colon): Ulcers (peptic ulcer disease) Reflux (gastroesophageal reflux disease) Hepatitis Liver failure Diverticulosis Kidney / bladder / prostate problems: Urinary infections (urinary tract infections) Kidney infections (pyelonephritis) Kidney dysfunction no dialysis (renal insufficiency) Kidney dysfunction dialysis (renal failure) Polycystic Kidney Disease Prostate enlargement (benign prostatic hypertrophy) Blood problems: Bleeding disorder Deep vein thrombosis Pulmonary Embolus Taking blood thinner (coumadin, warfarin, aspirin, etc.)..... Immune problems: HIV AIDS Psychiatric problems: Depression Anxiety Bipolar disorder Psychosis Cancer: Lung Thyroid Breast Colon Pancreas Prostate Kidney Melanoma Other problems: Rheumatoid Arthritis Marfan s disease Polyarteritis Nodosa Possible pregnancy (women of childbearing age) Please list other active medical problems not noted above: (These are problems for which you are currently taking medication or are seeing another physician) Page 2 of 5
3 Past Surgical History Surgeries: YES NO DATE(S) Brain surgery (craniotomy) Shunt Spinal surgery neck (cervical) Spinal surgery low back (lumbar).... Cataract surgery ( left; right) Heart bypass (CABG) Heart valve replacement Heart stent (angioplasty and stent).... Appendectomy Cholecystectomy Tonsillectomy Please list other surgeries: Medications: (please list all medications you are taking, including over-the-counter medications such as aspirin, ibuprofen, herbal medications, etc.) Name Dose Name Dose Allergies: (Please list all medication and non-medication allergies.) YES NO UKNOWN Do you have an allergy to latex? Page 3 of 5
4 Family history: (please indicate any major medical problems in your family) Yes No Brain aneurysm Cavernous malformation Hereditary Hemorrhagic Telangiectasia Neurofibromatosis ( Type I; Type II) Von Hippel-Lindau disease Brain tumor Stroke Hypertension Heart disease/heart attack Other family medical history: Personal / social history: Your height: Your weight: Tobacco use: Never Previously used Year when you quit: Packs/day when using: Recently quit Packs/day when using: Current: Number of years using: Packs/day now using: Other nicotine use (chewing tobacco, cigar, pipe) Alcohol use: Martial status: Never/rarely Occasionally/socially Moderate (2 drinks/day on average) Heavy (more than 2 drinks/day on average) Single Married Separated Widowed Divorced Work status: Currently employed Page 4 of 5
5 Occupation: Not currently employed Retired On disability When disabled? Reason for disability? Review of systems: Have you recently had any of the following symptoms?: YES NO Tiredness / fatigue Fevers Chills Sweat heavily at night (night sweats) Recent weight loss (unintentional) Headache Chest pain Palpitations (heart racing) Shortness of breath Difficulty breathing during physical activity Cough Heartburn (acid reflux) Nausea Vomiting Easy bleeding Easy bruising Diffuse joint pains (arthralgias) Muscle aches Anxiety Depression Please answer yes or no to the following: YES NO Is this a workman s compensation case? Is this related to an injury or car accident? Are you currently involved in any litigation or lawsuits? Have you consulted a lawyer about your injury/problem? Physician Signature Date Page 5 of 5
VASCULAR SURGERY PATIENT HEALTH HISTORY
VASCULAR SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications? To
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
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
Patient Name: Date of Birth:
Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?
PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:
1 NAME: DATE OF BIRTH PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS: PAST MEDICAL HISTORY (YOUR MEDICAL HISTORY) :
Patient Name Date of Birth Age. Other phone ( ) . Other
GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
Patient Interview Form
Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: tes: Contact Preference Email Telephone call/leave message Patient declines to specify Email Please check one
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Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency 1 2 3 4 5 6 7 8 9 10 11 12 13
Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)
Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / / Email Address: Do not have email Do not wish to provide Date of Birth: / / Gender: Male
DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
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:
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
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) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
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SURGERY SPECIALTY PATIENT HEALTH HISTORY
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PULMONARY MEDICINE PATIENT QUESTIONNAIRE
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Pulmonary & Sleep Consultants, LLC Serenity Sleep Institute Breathe Easier, Sleep Better www.pscssi.com Patient name DOB:. Referral doctor: Today s Date Reason for visit:. Height Weight BMI Neck size Temp