Patient History Form 2
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- Meghan Horn
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1 Patient History Form 2 : of Birth: Age: Name: Last First M.I. How did you learn about Dr. Barone? Primary Care Physician: Name: Address: Office Telephone: FAX: Pharmacy: Name: Telephone #: Address: Social History: Do you Smoke? YES NO If yes, # packs per day # of years. If you currently do not smoke when did you stop? Do you drink Alcohol? YES NO If yes, how much? Do you use Recreational Drugs? Describe
2 3 List ALL Medications you are taking or have taken within the last month (include aspirin, Motrin and herbal drugs): List All Drug Allergies including Latex, if none write NKDA : List ALL Surgical Operations and Hospitalizations you have ever had: //////////////////////////////////////// ////////////////////////////////////////
3 4a Medications to Avoid 3 weeks before Surgery The following drugs will have an undesirable side affect and will cause abnormal bleeding during your surgery. This is NOT a complete list, so please inform Dr. Barone of All of the medicines you normally take. This includes over the counter drugs and cold medicines. If you need to take a medication for pain prior to surgery, you may take Tylenol. Advil Darvon Compound Stendin Aleve Daypro Stanback Powder/ Alka-Seltzer Dristan Max Powder Alka_Seltzer Plus Duragesic St. John s Wort Anacin Ecotrin Stero-Darvon with Anaprox Empirin Aspirin Ansaid Emprazil Supac Argesic Excedrin Synalgos D.C. Arthropan Liquid Feldene Triaminicin Ascodeen-30 Four Way Cold Tablets Triagesic Ascriptin Fiorinal Ursinus Inlay Tabs Aspirin (all products) Fish Oil Vanguish Bayer Aspirin Ginkgo Biloba Vioxx BC Powders Ibuprofen (Motrin) Vitamin E Buff-A-Comp Measurin Vivo Med Buffadyne Midol Warfarin(Coumadin) Formula Monacet with Codeine ***All Herbal Meds Bufferin Momentum Muscular - Backache Norgesic Butalbital Pabirin Buffered Tablets Cama-Inlay Tabs Panalgesic Cama Arthritis Pain Reliever Caprin Capsules Panadynes Analgesic Celebrex Persistin Cheracol Capsules Plavix Congespirin Power Drinks Conaretol Robaxisal Cope Sine-Aid Coricidin Dolia Sine-Off Sinutab SX-65 Compound Capsule I have read the above list, received a copy and have no further questions. Patient
4 4b Medications to Avoid 3 weeks before Surgery The following drugs will have an undesirable side affect and will cause abnormal bleeding during your surgery. This is NOT a complete list, so please inform Dr. Barone of All of the medicines you normally take. This includes over the counter drugs and cold medicines. If you need to take a medication for pain prior to surgery, you may take Tylenol. Advil Darvon Compound Stendin Aleve Daypro Stanback Powder/ Alka-Seltzer Dristan Max Powder Alka_Seltzer Plus Duragesic St. John s Wort Anacin Ecotrin Stero-Darvon with Anaprox Empirin Aspirin Ansaid Emprazil Supac Argesic Excedrin Synalgos D.C. Arthropan Liquid Feldene Triaminicin Ascodeen-30 Four Way Cold Tablets Triagesic Ascriptin Fiorinal Ursinus Inlay Tabs Aspirin (all products) Fish Oil Vanguish Bayer Aspirin Ginkgo Biloba Vioxx BC Powders Ibuprofen (Motrin) Vitamin E Buff-A-Comp Measurin Vivo Med Buffadyne Midol Warfarin(Coumadin) Formula Monacet with Codeine ***All Herbal Meds Bufferin Momentum Muscular - Backache Norgesic Butalbital Pabirin Buffered Tablets Cama-Inlay Tabs Panalgesic Cama Arthritis Pain Reliever Caprin Capsules Panadynes Analgesic Celebrex Persistin Cheracol Capsules Plavix Congespirin Power Drinks Conaretol Robaxisal Cope Sine-Aid Coricidin Dolia Sine-Off Sinutab SX-65 Compound Capsule I have read the above list, received a copy and have no further questions.
5 Patient s Signature *********************Copy*******************Copy to be given to patient**************************** Review of Systems 5 Check Yes or No by the current ailment as it applies to YOU. If unsure, place a question mark (?) General Females ONLY yes no yes no Weight loss greater than 10 lbs in last year, Prior Breast Biopsy If Yes, how much? Breast Lumps Fever Bloody Nipple Discharge Trouble Sleeping Abnormal Mammogram Poor Appetite of Last Mammogram Birth Control? Eyes Method Glasses/Contacts Family History Breast Cancer Loss or Change of Vision Are you pregnant? Glaucoma or Cateracts Will you have any more children? Eye Surgery such as Lasix Dry Eyes Genitourinary Frequent use of Eyedrops Problems Urinating Difficulty starting stream Ear, Nose and Throat Painful/Burning/Frequent Urination Trouble breathing out of nose Nose bleeds Skin Hearing Aids/Hearing loss Skin Cancer Recurrent Ear Infections Where Sore throat/strep Throat Problems with Scarring Describe Cardiovascular Ever use Accutane? High Blood Pressure If Yes, when Heart Murmur Bruise easily? Mitral Valve Prolapse Irregular heartbeat Neuro Previous Heart Attack Blackouts/Fainting/Confusion Chest Pain Seizures Deep Vein Thrombosis (DVT) History of blood clots Psychiatric Respiratory Shortness of Breath Asthma If Yes, # times a week use an inhaler? History of Tuberculosis Chronic Cough Emphysema COPD (chronic obstructive pulmonary disease) History of Apnea Pulmonary Embolism (PE) Gastrointestinal Ulcers History of Jaundice (yellow skin) History Cirrhosis History Gallstones Severe Depression History Prior Counseling Endocrine Diabetes Thyroid Problems Allergy/Immunologic Latex Allergy HIV / AIDS Hepatitis A B C Food Allergies Use Recreational Drugs? Hematologic/Lymphatic Bleeding Disorders Enlarged Lymph Nodes
6 6 Patient Photographic Authorization and Release I,, authorize Dr. Constance M. Barone and/or Constance M. Barone, M.D., F.A.C.S. and her representative(s), to take photographs, slides and/or videotapes of me or parts of my body for the following procedure(s) and for medical purposes to be used for my care, medical presentation and/or articles. I also authorize the use of these images, without compensation to me, for the following specific purposes: (Please initial in the boxes marked Yes or No for each item) Yes No Medium In office Photo Album for prospective patients In office Seminars for prospective patients On Dr. Barone s Website for prospective patients In print Advertisements On Television Publication in Books and Journals I further understand that: 1. These photographs, slides or videotapes may be published By Dr. Constance M. Barone and/or Constance M. Barone, M.D., F.A.C.S. in any print, visual, or electronic media including, but not limited to, medical journals and textbooks, scientific presentations and teaching courses, and Internet web sites, for the purpose of informing the medical profession or the general public about plastic surgery methods. I understand that such uses may also include marketing on behalf of Dr. Constance M. Barone, for which Dr. Barone may receive direct or indirect remuneration. 2. I will not be identified by name in any of the media described above; however, I also understand that in some circumstances the photographs, slides, or videotapes may display features that identify me. 3. I have the right to revoke this authorization in writing at any time and, if I decide to do so, I must present my written revocation to Constance M. Barone, M.D., F.A.C.S.; 2829 Babcock Road, suite 615; San Antonio, Texas A revocation shall not affect any release of information made prior to revocation in reliance upon this Authorization. Patient s Signature
7 7 Patient Photographic Authorization and Release (Continued) 4. I may refuse to sign this authorization without affecting the medical treatment I receive from Dr. Constance Barone. 5. The information disclosed under this Authorization, or some portion thereof, is protected by state law and/or federal Health Insurance Portability and Accountability Act of 1996 ( HIPAA ). 6. I release and discharge Dr. Constance Barone and/or Constance M. Barone, M.D., F.A.C.S. from all liability including liability for negligence, that in any way arises out of any and all rights that I may have or may have had in regards to the photographs, slides or videotapes of me including any claim for payment in connection with any publication of them in any medium. I release and hold harmless Dr. Constance M. Barone and Constance M. Barone, M.D., F.A.C.S., and her staff and her employees from any and all claims or causes of action that I may have of any nature whatsoever, which in any manner result from the use of the photographs or other images. 7. This Authorization is made as a voluntary contribution in the interest of public education and I certify that I have read this Authorization and Release carefully and fully understand its terms and that Dr. Barone has answered all of my questions to my satisfaction. Patient s Signature
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FOLSOM CARDIOLOGY Please complete forms in black ink only Registration Form Office Use Only: Patient Acct # Name: Date of Birth: Address: Street City State Zip Code Phone: Work: Cell: Marital Status: S
Please describe, in detail, when the symptoms began:
161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On
Patient Health History Questionnaire
Patient Health History Questionnaire Manitou Springs Acupuncture Randall Johnson, L.Ac., LLC Certified Seitai Shinpo Acupuncturist License Number: Acu-0002072 Phone: (719) 237-4547 Email: 719acupuncture@gmail.com
PATIENT MEDICAL HISTORY
PATIENT MEDICAL HISTORY **All of the information requested is extremely important. We need complete and concise answers to** ALL of the questions in order to provide you with the safest and very best medical
Patient Information. Account #: Date: Person Responsible For Payment (Other than patient):
Patient Information Account #: Date: Race: Ethnicity: Tobacco Use: White or Hispanic Asian Black or African American Native Hawaiian or Pacific Islander American Indian or Alaskan Native Hispanic or Latino
SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE
Patient Name MRN DATE: SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE Date of birth Age REASON FOR VISIT Abnormal Mammogram R L please specify Lump/Thickening R L upper lower inner outer Pain R L upper
RAJIV SOOD MD, FACS AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY MEDICAL HISTORY Today s Date: Name Date of Birth
RAJIV SOOD MD, FACS AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY MEDICAL HISTORY 317-880-6825 Today s Date: Date of Birth Phone # Alternate # Age Height Current weight Significant other Name: Reason for
CENTRAL COAST ORTHOPEDIC MEDICAL GROUP Medical History Questionnaire GENERAL INFORMATION
GENERAL INFORMATION Last Name: First Name: What name do you prefer to be called? Age: DOB: / / Height: Weight: Left or Right Handed : Right Left Marital Status: M S D W Name of spouse or significant other:
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
Date: Referring Physician Dr. Phone: Primary Care Physician (if different) Dr. Phone:
Kuether Brain and Spine Todd Kuether, MD 19250 SW 65 th Avenue, Suite 260 Tualatin, OR 97062 501 N. Graham, MOB II #515, Portland, OR 97227 (503) 489-8111 Phone (503) 908-6800 fax kuetherbrainandspine.com
Name of Pa. tient: Last. First. per day) 50 mg. X-ray dye or. IV contract. Name (Last) (First) Address. City, state/ zip code
Division of Cardiology for the Academic Medical Center of the University of Texas Medical School at Houston NEW PATIENT HISTORY FORM Please complete and fax to 713-512-2245 Name of Pa tient: Last _ First
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
PATIENT MEDICAL HISTORY
GEORGIA BRAIN AND SPINE CENTER 4355 Johns Creek Parkway Suite 520 Suwanee, GA 30024 Phone: (404) 446-4424 Fax: (404) 446-4420 www.georgiabrainandspine.com PATIENT MEDICAL HISTORY **All of the information
We must receive these completed forms before your Procedure can be performed.
Joel J. Garsten, M.D., F.A.C.P., F.A.C.G., A.G.A.F. Bhupinder S. Lyall, M.D., F.A.C.P. Magdi Khalil, M.D. Albert R. Marano, M.D., F.A.C.P., F.A.C.G., A.G.A.F. Russell Parvin, M.D. Michele Pierce, PA-C
Florida Orthopaedic Institute Urgent Care
Date: Florida Orthopaedic Institute Urgent Care Patient Questionnaire Initial Evaluation Patient Name: MR# (Office Use only): Family/Primary Doctor: Phone: Family/ Primary Doctor Address: Who referred
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Medical Information. (office use) MRN: CMRN: Last Name: First Name: Middle Initial: Date of birth: Age: Sex: M F Height: Weight:
1835 W. County Rd C, Suite 80, Roseville, MN 55113 P: 651-797-6880 F: 651-797-6881 info@spartzvein.com spartzvein.com Medical Information Date of consultation: (office use) MRN: CMRN: Last Name: First
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
Dear Mercy Cancer Center Radiation Oncology Patient
Dear Mercy Cancer Center Radiation Oncology Patient Welcome to our Department. In order to complete our records, and enable our physicians to ensure that your questions are fully addressed, we appreciate
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
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
ALLERGIES (food,latex,other)
MEDICATION LIST NAME: DOB: Main Phone: (CELL or HOME) Initials Consent to Import Medication History I give Dr. Heniff consent to import my medication history as provided by SureScripts. ALLERGIES (food,latex,other)
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email: