RESEARCH PARTICIPANT REGISTRATION FORM
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- Percival Darrell Tucker
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1 RESEARCH PARTICIPANT REGISTRATION FORM PATIENT: DOB: AGE: DATE: Last Name First Name M.I. ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK PHONE: MOBILE: SOCIAL SECURITY NUMBER # (Why are we asking for this?*): - - *IRS requires that businesses report all payments made to each person to whom they have paid at least $600 in other income during the course of one year on form 1099-MISC (Miscellaneous Income). Social Security # and current address are required in order to report. ARE YOU A STUDENT? Yes No If yes, NAME OF SCHOOL: OCCUPATION: EMPLOYER: CHECK ALL OF THE FOLLOWING THAT APPLY: OKAY TO LEAVE A DETAILED MESSAGE: on home # on voic at work # on mobile # at a different phone #: OKAY TO LEAVE INFORMATION WITH: Spouse/partner (name): Other family member (relationship & name): OKAY TO LEAVE APPOINTMENT REMINDERS VIA: Phone Call Text Message OKAY TO SEND TEXTS ABOUT UPCOMING RESEARCH STUDIES: Yes No HOW DID YOU HEAR ABOUT US? Patient of our medical practice Print Ad: Previous study participant/screen Craigslist: Social Media: Facebook: Website: Other: Friend/Family/Co-worker (Name, so we can thank them: ) In Case of Emergency - Person to Be Notified NAME: HOME PHONE: SIGNATURE: RELATIONSHIP TO PATIENT: WORK PHONE: DATE: Seattle Women s: Health, Research, Gynecology is dedicated to providing exemplary health care for women of all ages. We offer a unique practice that integrates preventative care and medical treatment in addition to cutting-edge research. Our approach creates a standard of excellence in the specialized care of women.
2 INTAKE FORM Please use black or blue ink & do NOT print double-sided NAME DOB AGE DATE / / First MI Last How would you like to be addressed? Gender: Female Male Primary Care Pharmacy Name Address Telephone number Name Address Telephone number Reason for visit: If the reason for your visit is a STUDY, please initial the following statement: I am currently not participating in any other clinical trials at other locations Condition MEDICAL HISTORY AND REVIEW OF SYMPTOMS When? Dermatological (Skin) Precancer/Cancer Rash Abnormal mole Other skin conditions: Neurological (Nervous system) Migraines / Headaches Depression Anxiety Psychiatric Care/ Hospitalization Epilepsy/Seizures Other: Cardiovascular (Heart & blood) Heart Murmur Irregular Heart Rate/Palpitations Chest Pain Heart Attack High Blood Pressure Elevated Cholesterol Other: Pulmonary (Lungs) Asthma COPD First Diagnosed Resolved Taking Medication? Office Use Only
3 Persistent Cough Other: Gastrointestinal (Digestion) Ulcers Hepatitis / Liver Problems Gall Bladder Disease Heartburn/GERD Chronic Constipation Diarrhea Persistent Nausea Vomiting Blood in Stool Other: Urologic (Kidneys & Bladder) Frequent Urinary Tract Infection Kidney Infection Kidney Disease Bladder Problems Incontinence (leaking) Urinary Frequency Urinary Urgency Blood in Urine Other: Musculoskeletal(Muscles& Bones) Osteoporosis Osteopenia Arthritis: Type Fibromyalgia Fractures Other: Eyes, Ear, Nose, Throat Glaucoma -Type Hearing Problems Seasonal Allergies/Hay Fever Cataracts Other eye problems: Current dental issues? Yes No Other: Endocrine (Glands) Diabetes Mellitus: Type I or II Thyroid Disease Other: Hematology (Blood Disorders) Anemia Blood Clots / Pulmonary Embolism Other: Lupus/ SLE Cancer Cancer Type: Cancer Type: Cancer Type: Cancer Type: SURGICAL HISTORY (Including Cosmetic Surgery)
4 Surgery type (s) Reason Where was it done (Hospital/City)? FAMILY MEDICAL HISTORY Relative Living? Major Medical Problems (i.e. stroke, heart attack) Mother Father Siblings Siblings Siblings Other CURRENT MEDICATIONS Medications you are taking currently (include those you buy at the drug store, health food store) Medications, Vitamins, Dose How often? Start Stop Reason taken and/or Health supplements (e.g. 10mg) (e.g. twice a day) (If applicable) (e.g. cholesterol) Other Medications you have taken in the past 3 months
5 MEDICATION(DRUG) / FOOD ALLERGIES Medication or Food Reaction you first had this reaction Occupation: PERSONAL HEALTH HABITS Single Partnered Married Widowed Divorced Separated Tobacco use? How much per day? Year started Year quit Alcohol use? YES NO Average number of drinks per week Current or past history of substance abuse? YES NO s: Do you exercise? How often? Any dietary restrictions? IMMUNIZATIONS Yearly flu shot? YES NO of last tetanus shot (recommended every 10 years) Have you had a Measles/Mumps/Rubella vaccine? YES NO Have you had a varicella vaccine (or had chicken pox)? YES NO If age 65 or over, have you had a pneumococcal vaccine? YES NO Ever been tested for Tb? YES NO Was it positive? YES NO BCG Vaccine YES NO Have you had the series of vaccines for HPV (Human Papilloma Virus)? YES NO I ve had: All three vaccines The first one only Two vaccines FEMALES: Type of Delivery OBSTETRIC HISTORY (PREGNANCY) Complications of pregnancy OTHER PREGNANCIES- MISCARRAGES/ ABORTIONS/ ECTOPICS Outcome
6 GYNECOLOGICAL HISTORY Last Menstrual Period: Method of Birth Control: Age of 1 st menstrual period: Menses last days and come every days : heavy medium light Last Pap: If any abnormal paps, when and how was it treated: Last mammogram: Where: Any abnormal mammograms and when: Breast procedures/ Ultrasound/ MRI? Breast Implants? Type: Lifetime sexual partners > 20 Condition When? First Diagnosed Genital Infections: Bacterial Vaginosis Gonorrhea HPV Chlamydia Herpes Other: Uterine fibroids Resolved Taking Medication? Office Use Only Ovarian Cyst Vaginal Dryness Decreased Sex Drive Painful intercourse Irregular Bleeding Painful Periods Other: MALES: Condition When? Reproductive Genital Infections: Bacterial Vaginosis Gonorrhea HPV Chlamydia Herpes Other: Prostate Problems Decreased Sex Drive Erectile Dysfunction First Diagnosed Resolved Taking Medication? Office Use Only Other: Patient Signature Reviewed by Provider: Reviewed by CRC (if applicable)
7 MAP AND DIRECTIONS From North or South via I-5 1. Take I-5 to the 45th Street exit 2. Turn East onto NE 45th Street 3. Continue on NE 45th Street past the University of Washington and down the hill 4. Turn left at the stoplight and continue on NE 45th Street past University Village to the 5-way intersection. There are two left turn lanes - choose the one on the right 5. Take a soft left onto NE 45th Place 6. Take an immediate left into one of the two parking lots at the Lakeview Medical Dental Building. We are on the ground floor in Suite #100. From the East via Take the Montlake Blvd North exit. 2. Merge onto Montlake Blvd. E. 3. Follow Montlake Blvd. as it curves to the east, merge onto NE 45th Street. 4. Continue on NE 45th Street past University Village to the 5-way intersection. There are two left turn lanes choose the one on the right. 5. Take a soft left onto NE 45th Place 6. Take an immediate left into one of the two parking lots at the Lakeview Medical Dental Building. If these two lots are full, additional parking may be found across the street. We are on the ground floor in Suite #100. Via Seattle Metro Transit 1. Plan your trip at 2. Bus routes 25, 65, and 75 all have stops within one block of our building.
8 PARKING MAP There have been recent changes to our available parking spaces. The map below has been created to display available parking lots. These spaces are free and are reserved for Lakeview Medical Dental Building patients. Parking can be found in our front lot, back lot and a parking garage. The parking garage is accessible through the back lot. **NOTE: The garage closes promptly at 7:00 PM. If you do NOT move your car before 7:00 PM you will be unable to move your car until next business day KEY PATIENT PARKING SEATTLE WOMEN S
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