M F HOME ADDRESS CITY STATE ZIP CODE MARITAL STATUS SINGLE MARRIED DIVORCED WIDOWED PREFERRED PHONE NUMBER TO BE CONTACTED
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1 PRESENT ILLNESS INFORMATION INSURANCE PATIENT HISTORY AND PHYSICAL APPOINTMENT DATE: NAME-LAST FIRST M.I. DATE OF BIRTH AGE SEX SOCIAL SECURITY NO. M F HOME ADDRESS CITY STATE ZIP CODE MARITAL STATUS SINGLE MARRIED DIVORCED WOWED PREFERRED PHONE NUMBER TO BE CONTACTED IN CASE OF EMERGENCY CONTACT NAME EMERGENCY CONTACT PHONE RELATIONSHIP PRIMARY CARE PHYSICIAN DATE OF LAST VISIT EMPLOYER/OCCUPATION PREFERRED PHARMACY AND PHONE NUMBER WHO SHOULD WE THANK FOR YOUR REFFERAL REFERRING PHONE NUMBER (IF APPLICABLE) INSURANCE COMPANY EMPLOYER OF INSURED OR POLICY NUMBER POLICY HOLDER OR INSURED NAME GROUP NUMBER PRE-CERTIFICATION PHONE NUMBER 1) 2) SYMPTOMS OR REASON FOR VISIT CURRENT SEVERITY OF PROBLEM PLEASE RATE YOUR CONDITION ON A SCALE OF 1-10 WITH 1 BEING NORMAL LIFESTYLE AND 10 BEING SEVERE EFFECTS ON LIFESTYLE PREVIOUS TREATMENTS FOR PROBLEM (MEDS OR SURGERY, ETC.) 3) WHEN D YOU FIRST NOTICE THE PROBLEM? HOW OFTEN DO YOU HAVE THESE PROBLEMS? FAMILY HISTORY OF SIMILAR PROBLEMS 4) YES NO WHAT IS THE MEDICAL PROBLEM YOU NEED ADDRESSED TODAY? DOES ANYTHING MAKE YOUR PROBLEM WORSE OR BETTER? HAVE YOU BEEN EVALUATED FOR THIS PROBLEM BEFORE (WHAT WAS THE DIAGNOSIS GIVEN?) PAGE 1 OF 6
2 IMPLANTS MEDICATIONS ALLERGIES PLEASE LIST ALLERGIES (MEDICATIONS OR FOODS) TYPE OF REACTION (RASH, BREATHING, ETC.) PLEASE LIST ALL MEDICATIONS (INCLUDING OVER THE COUNTER, VITAMINS AND HERBALS) STRENGTH AND FREQUENCY PLEASE LIST ALL IMPLANTS (PENILE, BREAST, PACER, ETC.) PAGE 2 OF 6
3 HOSPITALIZATIONS MEDICAL HISTORY/ CURRENT ILLNESSES P L E A S E C H E C K Y E S I F Y O U H A V E E V E R H A D A N Y O F T H E F O L L O W I N G C O N D I T I O N S ANEMIA IRREGULAR HEARTBEAT ASTHMA HIGH CHOLESTEROL ARTHRITIS JAUNDICE BLADDER DISEASE KNEY FAILURE BLEEDING TENDENCIES KNEY STONES BRONCHITIS MEASLES CANCER MENTAL ILLNESS CATARACTS MUMPS CHICKEN POX POLIOMYELITIS DEMENTIA (MEMORY PROBLEMS) RHEUMATIC FEVER DIABETES MELLITUS SCARLET FEVER EMPHYSEMA SEXUALLY TRANSMITTED DISEASE GALLBLADDER DISEASE SEIZURES GASTRO-ESOPHAGEAL REFLUX DISEASE SKIN LESIONS / SEVERE RASH GLAUCOMA SICKLE CELL DISEASE HEARING LOSS STROKE HEART DISEASE / HEART ATTACK THYRO DISEASE HEPATITIS: A B C TUBERCULOSIS HIGH BLOOD PRESSURE OTHER MEDICAL CONDITIONS HIV / AS PLEASE LIST MAJOR HOSPITALIZATIONS AND SURGERIES YEAR PAGE 3 OF 6
4 FAMILY MEDICAL HISTORY SOCIAL HISTORY LEVEL OF EDUCATION: HIGH SCHOOL COLLEGE GRADUATE SCHOOL OCCUPATION PLEASE LIST ALL EXPOSURES TO TOXIC CHEMICALS OR GASES LIVES WITH HOBBIES TRAVEL HISTORY (PLEASE LIST TRAVEL TO FOREIGN COUNTRIES OVER THE 3 YEARS) TOBACCO (CIGARETTES, SNUFF, CHEWING, PIPES, CIGARS) AMOUNT ALCOHOL ILLICIT DRUGS EXERCISE AMOUNT TYPE OF DRUGS AMOUNT P L E A S E A N S W E R Q U E S T I O N S R E G A R D I N G F A M I L Y M E D I C A L H I S T O R Y MOTHER S AGE (OR AGE AT DEATH) AND MEDICAL PROBLEMS (IF NOT LISTED BELOW) ALIVE FATHER S AGE (OR AGE AT DEATH) AND MEDICAL PROBLEMS (IF NOT LISTED BELOW) ALIVE ALZHEIMER S DISEASE HEART PROBLEMS ASTHMA HEARING LOSS ARTHRITIS KNEY DISEASE CANCER THYRO DISEASE CATARACTS HIGH BLOOD PRESSURE DIABETES OTHER MAJOR FAMILY MEDICAL PROBLEMS EPILEPSY PAGE 4 OF 6
5 SIGNATURES REVIEW OF SYSTEMS P L E A S E C I R C L E A N Y O F T H E F O L L O W I N G S Y M P T O M S Y O U H A V E E X P E R I E N C E D I N T H E P A S T 6 M O N T H S GENERAL BLOOD SKIN EASILY FATIGUED ANEMIA (LOW BLOOD COUNT) BLEEDING FATIGUED ONLY AFTER EXERCISE BLEEDING DISORDERS EASILY BRUISING FATIGUED UPON WAKING TAKING COUMADIN EXCESSIVE WEIGHT GAIN EASY CLOTTING EXCESSIVE WEIGHT LOSS BLOOD CLOT SORES ITCHING SCALING NIGHT SWEATS DVT VARICOSE VEINS FEVER NON HEALING LEG / FOOT WOUNDS GLANDS ENLARGEMENT PAIN DRAINAGE LYMPHOMA EYES GLASSES CATARACTS TRAUMA INFECTION TEMPORARY BLINDNESS VISUAL LOSS GLAUCOMA EAR INFECTION LOSS OF HEARING PAIN RINGING IN THE EARS RUPTURED EAR DRUM NOSE MOUTH /THROAT NECK SINUS INFECTION CHEWING LIMITATION OF MOVEMENT NOSE BLEEDS EXCESSIVE TONGUE MOVEMENT RESPIRATORY ASTHMA COUGHING HEART / CV IRREGULAR HEART BEAT RUNNY NOSE PAIN DENTURES FREQUENT SORE THROAT HOARSENESS PAIN STIFFNESS TRAUMA WEAKNESS SWELLING CHEST PAIN LUNG INFECTIONS COLD HAND AND / OR FEET COUGHING UP MUCUS PAIN IN LEGS AFTER WALKING GI NAUSEA INDIGESTION VOMITING ABDOMEN PAIN GENITOURINARY SKELETAL NEUROLOGICAL PSYCHIATRIC CHANGE IN COLOR OF URINE GENERALIZED WEAKNESS OF MUSCLES DIZZINESS MEMORY LOSS DECREASED URINATION MUSCLE PARALYSIS FALLS / BALANCE FOCUSING PAINFUL URINATION DECREASE IN MUSCLE SIZE SLURRED SPEECH DEPRESSION FREQUENT URINATION AT NIGHT DECREASE IN MUSCLE STRENGTH SEVERE HEADACHES MOOD SWINGS COUGHING UP BLOOD PALPITATIONS VOMITING BLOOD INCREASED URINATION INVOLUNTARY MOVEMENT SEIZURE SLEEP DISTURBANCE SHORTNESS OF BREATH AT REST SHORTNESS OF BREATH JAUNDICE (YELLOW SKIN) CHANGE IN MENSTRUAL CYCLE ARTHRITIS BURNING PAIN / NUMBNESS / TINGLING BLACK OUTS PAIN OR SWALLOWING SHORTNESS OF BREATH AFTER EXERTION SWELLING OF HANDS AND/OR FEET BLOOD IN STOOL ERECTILE DYSFUNCTION / IMPOTENCE JOINT PAIN LOW BACK PAIN LIGHT HEADEDNESS THE FOLLOWING QUESTIONNAIRE IS INTENDED TO HELP US BETTER EVALUATE AND TREAT YOUR MEDICAL PROBLEMS. WE APPRECIATE YOU FILLING IT OUT IN ITS ENTIRETY. SHOULD YOU HAVE ANY QUESTIONS ABOUT WHAT INFORMATION TO INCLUDE DON T HESITATE TO ASK THE OFFICE STAFF. PATIENT SIGNATURE DATE PHYSICIAN SIGNATURE DATE PAGE 5 OF 6
6 CODING ASSESMENT / PLAN PHYSICAL EXAMINATION PHYSICIAN USE ONLY BELOW PROBLEM FOCUSED 1-5, EXPANDED PROBLEM FOCUSED 6, DETAILED 12, COMPREHENSIVE ALL SHADED PLUS 1 UNSHADED HEIGHT * WEIGHT * BP * TEMP * PULSE * RESP * CONSTITUTIONAL * NORMAL WD WN HEENT * NORMAL EOMI JVD SUPPLE BRUIT MP SCORE RESPIRATORY * NORMAL CTA TRACH MLINE RESP EFF CARDIOVASCULAR * NORMAL MURMUR RUB BRUIT EDEMA PULSES ABDOMEN * NORMAL BS MASSES TENDERNESS PELVIC / RECTAL NORMAL DEFFERED SKIN NORMAL CLUBBBING CYANOSIS RASH LESION VARICOSITIES MS NORMAL GAIT UNSTEAD WEAKNESS NEUROLOGICAL NORMAL STRENGTH GRIP CN II-XII PSYCHIATRIC NORMAL ORIENTATION MS MOOD AFFECT OTHER FINDINGS TESTS ASSESMENT PLAN FOLLOW UP DAYS WEEKS MONTHS PRN I HAVE DISCUSESED THE RISK, BENEFITS, OPTIONS AND ALTERNATIVES WITH THE PATIENT PHYSICIAN SIGNATURE TOTAL TIME DATE HPI HISTORY REVIEW OF SYSTEMS PHYSICAL EXAMINATION TYPE C BRIEF 1-3 N/A N/A 1-5 ELEMENTS PROBLEM FOCUSED BRIEF 1-3 N/A PERTINENT PROBLEM 1 AT LEAST 6 ELEMENTS EXPANDED EXTENDED >4 PERTINENT 1 EXTENDED 2-9 AT LEAST 12 ELEMENTS DETAILED EXTENDED >4 COMPLETE 3 COMPLETE >= 10 ALL SHADED * & 1 UNSHADED COMPREHENSIVE PAGE 6 OF 6
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Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
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