NEW CLINIC PATIENT QUESTIONNAIRE
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- Aileen Curtis
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1 Washington Heart Rhythm Associates, LLC Pirooz Mofrad MD, FACC, FHRS New Hampshire Avenue, Suite 204 Silver Spring, MD Telephone: Fax: NEW CLINIC PATIENT QUESTIONNAIRE Name (Last, First) Birthdate Age Sex M F Appointment Date Clinic Physician Did another physician refer you? Yes No Self-Referral Referring MD Name Street Address City, State, Zip Code Phone ( ) Fax ( ) If you have a primary physician, other than the referring physician, please complete so we can send them a report of your office visit Primary Care MD Name Street Address City, State, Zip Code Phone ( ) Fax ( ) Would you like this clinic s visit information sent to any physician other than those listed above? Yes No MD Name Street Address City, State, Zip Code Phone ( ) Fax ( ) What is the reason for your clinic appointment today? Past Medical History
2 Please indicate if you have ever been diagnosed with any of the following conditions. If Yes, please give an explanation. SYSTEM YES NO PATIENT COMMENTS CARDIOVASCULAR Atrial Fibrillation Blood Clotting Disorder Carotid Artery Disorder Congestive Heart Failure Elevated Cholesterol Heart Murmur Heart Attack/Angina Heart Surgery/Angioplasty High Blood Pressure Prosthetic/Artificial Heart Valve Blockage of Arm/Leg Vessels GASTROINTESTINAL/ GENITOURINARY/ RESPIRATORY Stomach Ulcers Liver Disease/Hepatitis Kidney/Bladder Disease Lung Disease Tuberculosis OTHER Alcohol Dependency Cancer Diabetes Drug Abuse Immune System Disorder Thyroid Disease Toxic Exposure Sexually Transmitted Disease
3 OTHER PAST MEDICAL HISTORY (Please list all medical conditions not mentioned above) PREVIOUS OPERATIONS/HOSPITALIZATIONS: Date Hospital Problem/Operation CURRENT MEDICATIONS (Please list all medications, i.e. over-counter medications and herbal meds) Medications Dosage Number Taken Daily Allergy History Have you ever had an allergic reaction to any medication? Yes No If yes, please list medication and reaction. Social History Birthplace: Highest Grade completed in School: Current Occupation: Relationship/Marital status:
4 Have you ever smoked cigarettes: Yes No If yes, how much do you currently smoke per day? ½ pack 1 pack 2 packs > 2 packs If you previously smoked, how long ago did you quit? 1 year 1-5 years > 5 years How many years did you smoke? Have you had significant exposure to: Pesticides? Yes No Do you drink alcohol? Yes No Type How often/much? Do you exercise? Yes No If yes, how much? Rarely Occasionally >3 times/week Dietary Restrictions? Family History: Family Member Age (or age at death) Medical Problems Grandparents Father Mother Siblings Children Review of Systems Have you experienced any of the following symptoms? Please circle Yes, No, or Unknown. If Yes, please give an explanation.
5
6 *I have truthfully to the best of my knowledge, included all of the information requested above. Patient Signature Date *I have reviewed the information contained in this questionnaire and have reviewed the pertinent findings with the patient and/or family. Physician Signature Date
NEUROSURGERY PATIENT INTAKE FORM
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Cell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
New Patient Questionnaire
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ADULT INFORMATION SHEET
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PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT
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Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
Please complete and return to the office prior to your appointment.
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CORAL REEF CHIROPRACTIC CENTER, PA NAME (Last, First, Middle Initial) HOME PHONE TODAY S DATE COMPLETE ADDRESS (Include City, State & Zip) CELL PHONE DATE OF BIRTH OCCUPATION EMPLOYER NAME EMAIL AGE SEX
Do you currently have a family physician?: If not, where have you been getting health care?:
Adult Intake Form Preferred Location: Cambridge Kitchener Apply Patient Label here First Name: Last Name: Gender: Address: Phone number: Date of Birth: Health Card Number:_ Do you currently have a family