TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
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1 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 Alzheimer s Disease Deep Vein Thrombosis Cerebral Aneurysm Heart Attack Peripheral Neuropathy Heart Murmur Seizure Disorder High Blood Pressure Stroke High Cholesterol TIA Irregular Heartbeat (Atrial Fibrillation) URINARY PROBLEMS LUNG PROBLEMS Kidney Infection (pyelonephritis) Asthma Kidney Stones Chronic Obstructive Pulmonary Disease Prostate Enlargement Emphysema Urinary Tract Infection Pneumonia Pulmonary Embolism BLOOD DISORDERS Anemia GASTROINTESTINAL PROBLEMS Bleeding Disorder Cirrhosis Blood Transfusion Gastric Ulcer HIV Positive Gastroesophageal Reflux Disease Hepatitis CANCER Type: ENDOCRINE PROBLEMS Type: Diabetes, Type I (Juvenile Onset) Diabetes, Type II (Adult Onset) ANESTHESIA Thyroid Disorder: Type: Have you ever had a reaction to anesthesia? Yes No MUSCULOSKELETAL Please Describe: Osteoarthritis Osteoporosis PAST SURGICAL HISTORY : (Please list all previous surgeries) Date of Surgery Procedure Performed Surgeon s Name 1
2 Patient Name: Date of Birth: MEDICATION LIST Please include all prescription, over-the counter, and herbal medications you are taking. If additional space is required, please attach your medication list to this form. Medications Dosage Quantity Times Taken Per Day Date Started Date Stopped 1
3 Patient Name: Date of Birth: DRUG ALLERGIES AND REACTIONS: Drug Name Allergic Reaction Are you allergic to latex? Circle One: YES NO FAMILY MEDICAL HISTORY (Please list any medical conditions in your family) Relationship to Patient Living/Deceased Age Medical Conditions Mother Father Grandmother Grandfather Brother Sister Child SOCIAL HISTORY (Have you ever used the following?) Tobacco Use Circle One: Never Current Former Alcohol Use Circle One: Never Current Former Recreational Drug Use Circle One: Never Current Former Regular Exercise: Circle one: YES NO How Often? 3
4 Patient Name: Date of Birth: DIALYSIS INFORMATION: (If applicable) Type: Circle One: HEMO-DIALYSIS PERITONEAL (PD) Days: Circle One: Mon Tue Wed Thu Fri Sat Dialysis Center: Address: City: State: Zip: Telephone Number: Fax Number: Nephrologist: Patient Name: Date of Birth: 4
5 Patient Name: Date of Birth: REVIEW OF SYSTEMS (ROS): To be completed by patient ARE YOU EXPERIENCING ANY OF THE FOLLOWING? PLEASE CIRCLE Y FOR YES AND N FOR NO CONSTITUTIONAL RESPIRATORY MUSCULOSKELETAL Weight Gain Y N Wheeze Y N Muscle Pain Y N Weight Loss Y N Cough Y N Joint Pain Y N Fever Y N Bloody Sputum Y N Joint Swelling Y N Chills Y N Other Y N Weakness Y N Fatigue Y N Poor Balance Y N Loss of Appetite Y N Other Y N Night Sweats Y N GASTROINTESTINAL Other Y N Abdominal Pain Y N Nausea Y N ENDOCRINE Vomiting Y N Excessive Sweating Y N EYES Diarrhea Y N Excessive Thirst Y N Pain Y N Constipation Y N Excessive Heat Y N Discharge Y N Heartburn Y N Excessive Cold Y N Light Sensitivity Y N Blood in Stool Y N Other Y N Blurred Vision Y N Other Y N Double Vision Y N Other Y N PSYCHIATRIC GENITOURINARY Anxiety Y N Frequency Y N Depression Y N EAR, NOSE, THROAT Incontinence Y N Stress Y N Sore Throat Y N Flank Pain Y N Other Y N Hoarseness Y N Blood in Urine Y N Ringing in Ears Y N Other Y N Nose Bleeds Y N HEME-LYMPH Hearing Loss Y N Easy Bruising Y N Other Y N INTEGUMENT Swollen Glands Y N Rash Y N Excessive Bleeding Y N Moles Y N Other Y N BREASTS Sores Y N Breast Discharge Y N Breast Discharge Y N Other Y N Other: Y N ALLERGIC-IMMUNOLOGIC Sinus Allergy Symptoms Y N Frequent Illnesses Y N CARVIOVASCULAR NEUROLOGICAL Chest Pain Y N Headaches Y N Height: Palpitations Y N Confusion Y N Calf Pain Y N Dizziness Y N Weight: Leg Pain Y N Memory Loss Y N Shortness of Breath Y N Seizure Y N Other Y N Other Y N Reviewed and discussed with patient. Physician Signature: Date Reviewed: 5
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
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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
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
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
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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) :
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Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
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
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY NAME: _ DATE: Please complete the following questionnaire as completely as possible. 1. MEDICAL HISTORY Please list all current and prior health problems,
Wisconsin Integrative Pain Specialists
Patient Information Today s Date: Patient s Name: DOB: Age: Gender: Marital Status: M S D What would you like us to call you? Address: City, State, Zip: Home Phone: Cell Phone: Work Phone: Email: Preferred