History taking in paediatrics PROF. DR STANISŁAW POPOWSKI REGIONAL SPECIALIZED CHILDREN S HOSPITAL IN OLSZTYN
|
|
|
- Caitlin Gallagher
- 5 years ago
- Views:
Transcription
1 History taking in paediatrics PROF. DR STANISŁAW POPOWSKI REGIONAL SPECIALIZED CHILDREN S HOSPITAL IN OLSZTYN
2 Paediatric history taking- Introduction Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem A large percentage of the time, you will actually be able to make a diagnosis based on the history alone The value of the history will depend on your ability to elicit relevant information Successful interviewing is for the most part dependent upon your already well developed communication skills
3 Paediatric history taking- Introduction Observe the child at play in the waiting area and observe their appearance, behaviour and gait as they come into the clinic room The continued observation of the child during the whole interview may provide important clues to the diagnosis and management When you welcome the child, parents and siblings, check that you know the child s first name and gender
4 Paediatric history taking- Introduction Introduce yourself Determine the relationship of the adults to the child Establish eye contact and rapport with the family. Infants and some toddlers are most secure in parents arms or laps. Young children may need some time to get to know you Ensure that the interview environment is as welcoming and unthreatening as possible. Avoid having desks or beds between you and the family, but keep a comfortable distance
5 Paediatric history taking- Introduction Have toys available, observe how the child separates, plays and interacts with any siblings present Do not forget to address questions to the child, when appropriate
6 Paediatric history taking- the history must be adapted to the child s age Birth history and impact of children s growth and development Often distracted by presence of the child Need to be flexible Maintain a sense of humour Whenever you consider a paediatric problem, whether medical, developmental or behavioural, first ask, What is the child s age?
7 Paediatric history taking- the history must be adapted to the child s age older children &teenagers There will be occasions when the parents will not want the child present or when the child should be seen alone This is usually to avoid embarrassing older children or teenagers or to impart sensitive information This must be handled tactfully, often by negotiating to talk separately to each in turn.
8 Opening the consultation-these questions may need to be addressed at the patient s parents, depending on their age, so adjust as appropriate. Introduce yourself name / role Confirm patient details name / DOB Explain the need to take a history Gain consent to take a history Ensure the patient is comfortable
9 Presenting complaint Give the patient time to explain the problem/symptoms they ve been experiencing A paediatric history often relies on collateral information from the parents It s important to use open questioning to elicit the patient s or parent s presenting complaint So what s brought your child in today? or What s brought you in today? This can sometimes be difficult when talking to children and you may need to adopt an approach involving more direct questioning. So instead of saying Tell me about the pain you may need to ask a series of questions requiring only yes or no answers.
10 General enquiry General health how active and lively? Normal growth Pubertal development (if appropriate) Feeding/drinking/appetite Any recent change in behaviour or personality.
11 Systems review Make sure that you and the parent or child mean the same thing when describing a problem General rashes, fever (if measured) Respiratory cough, wheeze, breathing problems ENT throat infections, snoring, noisy breathing (stridor) Cardiovascular heart murmur, cyanosis, exercise tolerance Gastrointestinal vomiting, diarrhoea/constipation, abdominal pain Genitourinary dysuria, frequency, wetting, toilet-trained Neurological seizures, headaches, abnormal movements Musculoskeletal disturbance of gait, limb pain or swelling, other functional abnormalities.
12 History of presenting complaint Onset when did the symptom start? / was the onset acute or gradual? Duration minutes / hours / days / weeks / months / years Severity e.g. if symptom is shortness of breath are they able to talk in full sentences? Course is the symptom worsening, improving, or continuing to fluctuate? Intermittent or continuous? is the symptom always present or does it come and go? Precipitating factors are there any obvious triggers for the symptom? Relieving factors does anything appear to improve the symptoms, e.g. an inhaler Associated features are there other symptoms that appear associated e.g. fever / malaise Previous episodes has the patient experienced this symptoms previously?
13 Key paediatric questions Feeding volume of intake / frequency of feeding Vomiting frequency / volume / timing projectile? / bilious? / blood? Fever confirmed using thermometer vs subjectively feeling hot? Wet nappies / urine output number of wet nappies a day in dehydration Stools consistency / steatorrhoea? (biliary obstruction) / red currant jelly (intussusception) Rash any obvious trigger? / distribution? / blanching? Behaviour irritability / less responsive Cough productive? / associated increased work of breathing? Rhinorrhoea often associated with viral upper respiratory disease Weight gain or loss check baby book if the parent has it with them Sleeping pattern more sleepy than usual? Unwell contacts often children become infected from unwell siblings
14 Pain if pain is a symptom, clarify the details of the pain using SOCRATES Site where exactly is the pain / where is the pain worst Onset when did it start? / did it come on suddenly or gradually? Character what does it feel like? (sharp stabbing / dull ache / burning?) Radiation does the pain move anywhere else? Associations any other symptoms associated with the pain Time course does the pain have a pattern (e.g. worse in the mornings) Exacerbating / relieving factors anything make it particularly worse or better? Severity on a scale of 0-10, with 0 being no pain and 10 being the worst pain you ve ever felt
15 Ideas, Concerns and Expectations often addressed to parents Ideas what are the patient s / parent s thoughts regarding their symptoms? Concerns explore any worries the patient / parent may have regarding the symptoms Expectations gain an understanding of what the patient / parent is hoping to achieve from the consultation
16 Summarising Summarise what the patient / parent has told you about the presenting complaint. This allows you to check your understanding regarding everything the patient/parent has told you. It also allows the patient/parent to correct any inaccurate information and expand further on certain aspects. Once you have summarised, ask the patient/parent if there s anything else that you ve overlooked. Continue to periodically summarise as you move through the rest of the history.
17 Past medical history Antenatal period illnesses or complications during gestation e.g. rubella Birth delivery complications / prematurity / birth weight Neonatal period illness /admission to special care baby unit (SCBU)? Medical conditions Previous hospitalisation when and why? Previous surgery Accidents and injuries remain vigilant for signs of nonaccidental injury
18 Drug history Regular medication e.g. inhalers for asthma Over the counter medication
19 ALLERGIES Known allergies
20 Developmental history Current weight and height weight is required to calculate drug doses Developmental milestones (are they on track for their given age?): e.g. sitting up, crawling, walking, talking, toilet training, reading Some key developmental milestones in infants and young children
21 Developmental history Parental worries about vision, hearing, development Previous child health surveillance developmental checks Bladder and bowel control Child s temperament, behaviour Sleeping problems Concerns and progress at nursery/school.
22 Immunisations Is the child up to date with their immunisations?
23 Dietary history Type of food? formula / breast milk / solids Intake e.g. how many ounces of milk? Frequency of feeding reduced or increased? Special dietary requirements? cow s milk intolerance / coeliac disease
24 Family history Family history of disease e.g. coeliac Genetic conditions e.g. cystic fibrosis Family tree useful to draw out if considering genetic disease
25 Social history Living situation accommodation / main carer / who lives with child? Second hand smoke exposure risk factor for otitis media / asthma Parent s occupation Pets important when considering allergies / asthma triggers Schooling stage of learning / any issues? Foreign travel may be important when considering certain diagnoses e.g. TB
26 Closing the consultation Thank patient Summarise the history
History Taking 3rd year Lecture. Thembi Katangwe 1st March 2011
History Taking 3rd year Lecture Thembi Katangwe 1st March 2011 Objectives To understand that the parent / guardian is the historian Build a rapport with parent/guardian as well as older children To understand
Clinical History. Dr. Rodney Martínez
Clinical History Dr. Rodney Martínez Standard (American version) Name: Address: Phone Number: Marital Status: Age: Gender: Chief complaint History of present illness; Health issues: Past medical history:
NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
Spine New Patient Questionnaire Rev
Spine New Patient Questionnaire Rev 10.13.10 Name: Male Female Temp: Height: Weight: Date of Visit: Date of Birth: Age Today: *Please note this is a multi-part questionnaire. When you are done, please
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
Medical History Form
Medical History Form Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best
Pain Drawing. Name: Today s Date: How were you referred to the office: Visual Analog Scale
Pain Drawing Name: Today s Date: How were you referred to the office: Please be sure to fill this out as accurately as possible. This will become part of your permanent medical record and will be used
Pediatric Case History Form
Pediatric Case History Form Patient s full name: Date of completion: Date of birth: Gender (circle one): Male Female Mother s full name: Father s full name: Legal guardian s full name(s): Person completing
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
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
IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED
Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Medical Interview 101
Medical Interview 101 Aekarach Ariyachaipanich, MD Division of Cardiovascular medicine 13.06.2017 Disclosure: I am not an English teacher Medical Interview 101 A D A P T F R O M P R E S E N TAT I O N O
Sleep History Questionnaire
Sleep History Questionnaire Name: DOB: Phone: Date of Consultation: Consultation is requested by: Primary care provider: _ Preferred pharmacy: Chief complaint: Please tell us why you are here: How long
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
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
School AGE Background
School AGE Background Information Sheet Please fill in as much of this form as you can. Not all areas will be relevant. The more information you give us, the better we can do our assessment. Every reference
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
PEDIATRIC HISTORY FORM
PEDIATRIC HISTORY FORM Today s Date: MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code:
Developmental-Behavioral Pediatrics Questionnaire for New Patients
Developmental-Behavioral Pediatrics Questionnaire for New Patients Date: Name of person completing questionnaire: Relationship to child: Email: IDENTIFYING INFORMATION: Information Child Name Child Birthdate
PAIN INFORMATION SHEET
PAIN INFORMATION SHEET PLEASE MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE SENSATIONS DESCRIBED BELOW. PLEASE USE THE APPROPRIATE SYMBOL & INCLUDE ALL AREAS. **** ==== OOOO XXXX //// ACHE **** NUMBNESS
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
Pediatric Intake Form
Patient Name DOB Pediatric Intake Form 1 Pediatric Intake Form Welcome. Our philosophy and approach to medicine is wholistic and seeks to understand all factors that may be affecting your health. This
Understanding Cough, Wheezing and Noisy Breathing in Children. Introduction
Understanding Cough, Wheezing and Noisy Breathing in Children Introduction Symptoms such as cough, wheezing or noisy breathing can be caused by a number of conditions. When these occur, it is natural for
COMPREHENSIVE HEALTH & WELLNESS PROFILE
Patient Name DOB COMPREHENSIVE HEALTH & WELLNESS PROFILE The human body is designed to be healthy. Throughout life, events occur which damage your natural health expression. As a full spectrum Chiropractic
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE
FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE Please circle answers to the questions that pertain to your problem. You may select more than one answer per question. This information will
Pain Clinic Packet Neal E. Coleman, MD Andrew Trobridge, MD Angelia Huffmeyer, FNP J. Mark Hannaford, PA Matthew Stinson, PA-C
Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed
Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#
Date Name / / last first middle initial Personal Health # - Male Female Home Address City Postal Code Home Telephone # Business Telephone # Cell # E-Mail Address Best way to contact you: Home # Work #
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
New Patient Specialty Intake Form Department of Surgery
This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient
Effective Case Presentations
Effective Case Presentations Alan Lefor MD MPH Department of Surgery Jichi Medical University 4 4 Alan Lefor 1. History The complete medical history always should have six parts It begins with the Chief
HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
1 UT Health Austin Comprehensive Pain Management New Patient Questionnaire Thank you for scheduling a visit with the Comprehensive Pain Management Care Team. The responses you provide to these questions
PEDIATRIC MEDICAL HISTORY QUESTIONNAIRE
Division of Otolaryngology Main Phone: 847 504-3300 Main Fax: 847 504-3305 Mihir Bhayani, MD Judy L. Chen, MD Mark E. Gerber, MD, FACS, FAAP Joseph Raviv, MD Ilana Seligman, MD, FACS, FAAP Michael J. Shinners,
Eloxatin Oxaliplatin concentrated solution for injection
Eloxatin Oxaliplatin concentrated solution for injection Consumer Medicine Information Please read this leaflet before you are given this medicine. What is in this leaflet This leaflet answers some common
Name. Date of Birth. Primary Care Doctor? Who is the Doctor that referred you to us? Name of person completing this form?
Orthopaedic Surgical Oncology of Arizona Dr Bruce A Mallin Dr Matthew J Seidel PATIENT HISTORY FORM To help us better understand your risk factors for cancer, please complete this medical history. Please
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM Last Name: First Name: Middle: Home Phone: Other Contact: Other Contact: DOB: Age: Sex: Name of Referring Physician: Phone: Fax: Address: City: State: Zip: Name
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
NEW PATIENT INFORMATION
OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C. 2407 Lenora Church Road / Snellville, Georgia 30078-6916 / 770-979-2731 Welcome to our office! Today's Date: / / Your Name: [ ] Male [ ] Female What
Room # Critical Care & Pulmonary Consultants, P.C.
Room # Critical Care & Pulmonary Consultants, P.C. Health History You have been scheduled for an appointment with Critical Care and Pulmonary Consultants, P.C. This health history will help us facilitate
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
Osher Center for Integrative Medicine Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician:
Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician: How did you hear about us? What are your goals for this visit? Where would you like to see improvement in your child s health?
EMORY SLEEP CENTER Sleep and Health Questionnaire
EMORY SLEEP CENTER Sleep and Health Questionnaire Demographics Today s Date: / / Name: Date of Birth: / / Address: Sex: Male Female City/State/Zip: Preferred Contact Number: Work Home Cell Occupation:
Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status
Workers Compensation Intake Form File Number (Office Use) Patient Information: Today s Date Home Phone Name Cell Phone I prefer to be called Preferred Contact Home Cell Email Social Security No. Date of
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
Chayapathy Jollu, MD Board Certified in Physical Medicine and Rehabilitation Patient Initial Pain Questionnaire
Patient Initial Pain Questionnaire Date: Last Name: First Name: Middle Name: Age: Gender: M F Right handed Left handed Referring Physician: Primary Care Physician: Address: Address: Phone: Phone: Fax:
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
Marcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)
Marcelo Garzon HOM.DSHomMed.Bsc. www.sagehomeopathy.ca (Please be certain that all in take forms are completed and returned on time) NAME: Personal Health History DATE: OHIP # D.O.B : AGE: PHONE: MAY WE
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire Name: MR#:_ Date: Date of Injury: Referred By: Age: Date of Birth: Handed: R L Ambidextrous Male Female **** Mark
Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider
NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C.
NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C. Past Medical History AIDS/HIV disease Anemia Asthma Bronchitis Cancer Date of last Chest X-ray Diabetes Mellitus, Type I Diabetes Mellitus,
Salt Lake Orthopaedic Clinic Initial Visit Form
Salt Lake Orthopaedic Clinic Initial Visit Form Name: Today s Date: Date of Birth: Age: Height: Weight: Handedness (R/L): Referring Physician: Primary Care Physician: Chief Complaint Why are you seeing
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E mail newsletters, reminders, statements, etc. Emergency Name: Phone: City: State: Zip: Home
Baptist Health Floyd 1850 State Street New Albany, IN Sleep Disorders Center Lung & Sleep Specialists. Date of Birth: Age:
Page 1 of 7 GENERAL INFORMATION Name: Date of Birth: Age: Social Security #: Sex: Height: Weight: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Employer s Name: Marital Status: Married
Allina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History
Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
Pandemic FLU. What you need to know
Pandemic FLU OR What you need to know Important note: Hygiene is the most important step in preventing the spread of flu. Pandemic Flu is it different to the normal flu? Yes it is a completely different
Patient Information Form
1 Today s Date: Patient s Name Date of Birth Your Name Relationship to Child Name of School Grade Teacher(s) Please list the problems with which you want help for this child: 1. 2. 3. 4. 5. 6. 7. Has the
PATIENT HISTORY FORM
BodyCheck Prevention & Health Physical Therapy Centre PATIENT HISTORY FORM Please assist us by answering the following questions as completely and accurately as possible. Your answers will assist us by
Dexamethasone is used to treat cancer. This drug can be given in the vein (IV), by mouth, or as an eye drop.
Dexamethasone Other Names: Decadron About This Drug Dexamethasone is used to treat cancer. This drug can be given in the vein (IV), by mouth, or as an eye drop. Possible Side Effects (More Common) Increased
Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
GENERAL INFORMATION HISTORY QUESTIONNAIRE Name: Today s Date: Age: Date of birth: Sex: M F SS#: Home Address: Cell Phone: Your doctor: Home Phone: Your Attorney (if any): If questions arise after today
Please fill out this form as completely as possible. This information will determine how we treat your pain problem.
Name Date of birth Age Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your
HD CLINIC MEDICAL HISTORY FORM
HD CLINIC MEDICAL HISTORY FORM Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the questions below as best as you can. If you need assistance, a caregiver/companion
BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM
PATIENT MEDICAL HISTORY FORM Name: Date: Social Security #: DOB: Height: Weight: Email: Primary Care Physician: Referred by: Pharmacy Name/Location/Phone Number: Dialysis Center and Phone Number (if applicable):
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:
Practice: Today s Date: Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E-mail newsletters, reminders, statements, etc. Address: City: State:
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last
CHRISTIANA SPINE CENTER NEW PATIENT QUESTIONNAIRE
CHRISTIANA SPINE CENTER NEW PATIENT QUESTIONNAIRE NAME Today s Date CHIEF COMPLAINT _ (Please use your pen to mark painful areas) Front Back Date of Birth When did the pain begin: Allergies and reaction:
Balance and dizziness questionnaire
Balance and dizziness questionnaire Name: DOB: Date: Please describe in your own words, the sensation you feel without using the word dizzy Please circle the symptom that brought you here today: Please
CHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit)
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit) Last name: First Name: Title: Mr. Mrs. Dr. Appt Date: Refer by: (Please provide name
Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
Name: Age: Date: Accompanied by Relationship E-mail: @ MEDICAL BACKGROUND INFORMATION Please name the professionals that you have seen for this condition: Name Specialty Town Phone Who is your primary
COMPREHENSIVE NEW PATIENT QUESTIONNAIRE
What brings you in today? What do you prefer to be called (nickname)? Please list all of your medical conditions. 1. 5. 2. 6. 3. 7. 4. 8. What surgical or medical procedures have you had in the past? 1.
DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM
Name: MR#: Date: DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM Referring Physician s Name: Primary Care Provider s Name: 1. What was/were your first movement disorder symptoms? What did you
AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
CUMMINS BEHAVIORAL HEALTH SYSTEMS, INC. CONSUMER MEDICAL HISTORY SELF-REPORT
Page 1 of 5 CUMMINS BEHAVIORAL HEALTH SYSTEMS, INC. CONSUMER MEDICAL HISTORY SELF-REPORT Please describe what problems you/consumer are having and why you are seeking treatment at this time. PRIOR MENTAL
Telephone Number Home: Work: Cell:
Page 1 of 7 Patient Name: DOB: Date: Address: Occupation: Telephone Number Home: Work: Cell: Emergency Contact: Relation: Telephone: Address: Referring Physician: Address: Telephone: ***ALL PATIENTS MUST
COPING WITH FLU AT HOME
COPING WITH FLU AT HOME Looking after the sick, including yourself Getting help for sick people in Canterbury Call your general practice team for advice 24/7 rather than visit if you think you may have
Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week
3 Washington Circle W, #207/208 Patient ame: Age: Chief Complaint: Please describe what you are being seen for today: What is your hand dominance (which hand do you write with)? Left Right Ambidextrous
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
Name: DOB: Age: Phone: Phone: Is this an injury related to a : (circle one) Other? Yes / No (Please Explain)
Family/Primary Doctor: Emergency Contact: Name Phone: Phone: Who referred you to our office? Who else have you seen for this condition? INSTRUCTIONS: Please provide the following information, in detail.
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID 83704 (208)884-2922 ***Questionnaire MUST be completed PRIOR to arrival for appointment*** Today s Date / / / / Last First MI DOB Referring
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP
NEUROLOGICAL SURGERY, P.C.
NEUROLOGICAL SURGERY, P.C. PATIENT INFORMATION Name Date of Birth Age Address City Sate NY Zip Home ( ) - Cell ( ) - Work ( ) - Ext: Email Address _ Sex M F Soc. Sec. #: / / Single Married Widowed Separated