Heart Murmur Chest Pain Palpitations Swelling of feet Shortness of breath
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- Nigel Benedict Bryan
- 6 years ago
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1 Neck: Goiter Lumps Swollen Glands Pain Respiratory: Cough Wheezing Shortness of breath Coughing up blood Cardiac: Heart Murmur Chest Pain Palpitations Swelling of feet Shortness of breath Gastrointestinal: Trouble swallowing Heartburn or gas Nausea Vomiting Rectal Bleeding Constipation Diarrhea Abdominal Pain Hemorrhoids Urology: Frequent urination Painful urination Blood in urine Stones Difficulty urinating/holding Musculoskeletal: Joint stiffness Arthritis Gout Backache Muscle pain or cramps Peripheral Vascular: Leg Cramps while walking Varicose Veins Thrombophlebitis Neurological: Fainting Blackouts Seizures Weakness Numbness Tremors Tingling of hand/feet Memory changes Psychiatric: Anxiety Depression Phobias Eating Disorder Confusion Speech/Memory disorder Endocrine: Hear or cold intolerance Excessive Sweating Excessive Urinating Excessive Hunger Anemia Easy Bruising or Bleeding Other: Have you ever been hit, slapped and/or kicked or otherwise physically hurt by someone? YES, in the past year YES, prior to this past year NO
2 Has anyone ever forced you into having any type of sexual activity? Yes Do you experience chronic pain? Yes If YES, how is your pain managed? (i.e. Physical Therapy, medication, etc.) OPERATIONS AND HOSPITALIZATIONS: Please list any surgeries and/or hospitalization reasons and date: ALLERGIES TO MEDICATIONS: CURRENT MEDICATION: (Please include any over-the-counter drugs as well as vitamins, aspirin, etc.) Medication Name Dose Frequency of Use If you need additional room, please list other medications on the back of this page.
3 FAMILY MEDICAL HISTORY Please check all that apply: Stroke Heart Disease High Blood Pressure Thyroid Disease Kidney Disease Diabetes Arthritis Osteoporosis Migraine Headaches Alcoholism Asthma Depression Anxiety Cancer (Type): Date of last Tetanus Vaccination: / / VACCINATIONS/PREVENTION Have you received any of the following vaccines: Have you had a blood test for Rubella (German Measles) Hepatitis A: Yes t sure Yes t sure Hepatitis B: Yes t sure Date of last Colonoscopy: / / Pneumo Vax: Yes t sure Check here if Not Applicable: How often do you wear seatbelts? Are there any firearms kept in your home? Yes NO Does someone have a Power of Attorney or Healthcare Proxy giving them the power to make decisions about your care in life-threatening situations? Yes Name of Person/Relationship: Do you have an Advanced Directive such as DNR (Do not resuscitate)? Yes GENDER IDENTITY Please list any questions, concerns or comments you have, if any, about your gender, gender identity (sense of your Femaleness or Maleness) or sexual concerns. SEXUAL ORIENTATION & SEXUAL HISTORY How do you identify yourself in terms of sexual orientation? Are you attracted to the following: (check all that apply) Men Women Transgender Men Transgender Women Asexual Questioning Have you had sex with the following: (check all that apply) Men Women Transgender Men Transgender Women
4 When you have sex, do you have the following: (check all that apply) Oral Sex Vaginal Sex Anal Sex How often do you use condoms when having the following: Always Sometimes Never When was the last time you had sex without using a condom? Do you have a Primary Sexual Partner? Yes Do you have any Casual Sexual Partners? Yes NO When was the last time you were tested for HIV? What were the results: Negative Positive Please check any of the following that may apply: Syphilis Gonorrhea Pelvic Inflammatory Disease Herpes Trichomonas Genital Warts Yeast Infections Bacterial Vaginosis Chlamydia Crabs For each of the above that you checked, please indicate the date of infection, treatment completed, were your partner (s) informed and/or if you need help telling your partner(s). Infection Date Treatment Completed Inform Your Partner Do you know or believe that any of your partners have had HIV or another sexually transmitted infection? Yes t Sure Have your current partners been tested for HIV or other sexually transmitted infections? Yes t sure What were their results? Negative Positive t Sure Are you satisfied with your sexual life? Yes t sure
5 GYNECOLOGIC HISTORY If not applicable due to sex and/or gender, Please check here and skip to Hormones Section. Age of First Menstrual Period: Date of Last PAP: Results: rmal Abnormal Have you ever had the following: (check all that apply) Abnormal PAP: Yes Ovarian Cysts: Yes Fibroids: Yes DES Exposure: Yes Have you had a Hysterectomy: Yes If YES, Why? Were your ovaries removed? Yes, One Yes, both If Menopausal or Postmenopausal, Please check here and skip to the next section. Date of Last Period: Frequency of Periods: Bleeding: Light Moderate Heavy Other bleeding: Yes Between Periods: Yes After penetrative sexual activity Do you experience any of the following symptoms with your period? (check all that apply) Headaches Weight Gain Swelling Cramps Anxiety Depression Other Are you currently using birth control? Yes If YES, which type: (check all that apply) IUD Condoms Foam Foam & condoms Patch Diaphragm Ring Depo Tubal Ligation Vasectomy Pills (how long?) Are you currently pregnant or planning to become pregnant? Yes If you have not begun Menopause, Please check here and skip to next section Age when Menopause began: Have you ever taken estrogen replacement? Yes Age when estrogen replacement was started: How long was the estrogen replacement used? What was the estrogen dose? Have you ever taken progesterone? Yes If YES, what was the name of the progesterone replacement? How often did you take it? (days per month) How long did you use it? What was the dose?
6 Please check any of the following symptoms of Menopause you are having: Hot Flashes Fatigue Anxiety Depression Insomnia Irregular Bleeding Vaginal Burning/Itching Vaginal Dryness Pain during Vaginal Penetration Other: OBSTETRIC HISTORY How many times have you been pregnant? How many pregnancy terminations have you had? How many miscarriages have you had? How many vaginal deliveries have you had? How many caesarean sections have you had? Have you had any of the following: (check all that apply) Ectopic Pregnancies Yes Gestational Diabetes Yes History of Infertility Yes HORMONES FOR GENDER/SEX TRANSITIONING If Not applicable, please check here and skip to the next section. Are you currently taking hormones for gender or sex transitioning purposes? Yes If Yes, how long have you been taking them? What hormones are you taking? Have you ever used transitioning hormones in the past? Yes If YES, to past or current hormone use, what type of complications, if any, have you experienced? What type, if any, of sex reassignment surgery have you had? What type, if any, of other feminizing or masculinizing procedures have you had? What type of complications, if any, have you experienced following such surgeries and/or procedures? What concerns or questions, if any, do you have regarding gender/sex transitioning?
7 LIFESTYLE & HEALTH HABITS Do you follow a special diet? Yes If YES, please check all that apply: Vegetarian Low Fat Low Carb High Fiber Calorie Restriction Other Have you ever hinged, purged or restricted your food intake? Yes, describe: What concerns do you have about your eating practices? How often do you exercise at a moderate or vigorous level for 30 minutes or more? What type of exercise and/or sports do you engage in? On a typical day, how many cups of caffeine containing beverages do you have? (coffee, tea, soda, energy drinks, etc). On a typical day, how many portions of calcium enriched foods do you eat? On a daily basis, how much calcium do you consume through tablets or chews? 500 mg mg SUBSTANCE USE HISTORY How many drinks containing alcohol do you have, on an average, per week? Have you ever been concerned about drinking? Yes t Sure Has anyone, including a family member, friend, or healthcare worker been concerned about your drinking or suggest you cut down? Yes t Sure Are you a former smoker? Yes N/A How long ago did you quit? How many cigarettes do you smoke per day? How old were you when you first started smoking? Have you tried to quit? Yes N/A Are you interested in quitting? Yes N/A Please check any of the substances listed below that you have used, even if it was only once: Marijuana Cocaine Crystal Meth Heroin Other Opiates (Oxycodone, Vicodin, etc.) Ecstasy Mushrooms LSD Other Substances When was the last time you used it and how often? How did you use it (i.e. Smoke, inject, etc.)
8 Did you ever share your needle, cooker, cotton, rinse or any other part of your set? Yes t Sure What type of problems has drug use cause for you (i.e. relationships with others, problems at work, depression, anxiety, physical health, etc. ) What concerns, if any, do you have about either your past or current drug use? Thank you for answering this comprehensive health history form. Your answers are confidential and will help us provide a more complete and knowledgeable care of you. If you have any questions, please see our clinic staff.
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1525 S. Alafaya Trail Unit 105 / Orlando, FL 32828 T: 407-282-4449 F: 407-282-4438 www.synergyspineinjury.com HEALTH HISTORY QUESTIONNAIRE Name: Date: Address: City: State: Zip: S.S. #: Cell Phone: Home
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
1405 NE Douglas Lee s Summit, MO Phone: Date: Fax: Female Information and Health Summary
Tracy Dryer, RPh Sheryl Pfeiler, Pharm D, RPh 1405 NE Douglas Lee s Summit, MO 64086 Phone: 816-524-8444 Date: Fax: 816-246-5493 Female Information and Health Summary Name Date of Birth Address City/State/ZIP
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
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:
University Gynecologic Oncology Associates
University Gynecologic Oncology Associates Medical History Form Date: Name: Date of Birth: / / GYNE HISTORY Age of first period? If you no longer have periods, at what age did they stop? Are you pregnant
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
Patient Medical History Form
Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Jeri Shuster, M.D., P.A.
Please help us to help you by completing this health history form. We will review together at your first visit. Included is potentially relevant Ob-Gyn, Medical, Surgical, and pertinent family history.
JOHN MICHAEL ROACH, MD
GASTROENTEROLOGY JOHN MICHAEL ROACH, MD 520 N. 4 TH AVE. PASCO, WA 99301 Phone: (509) 546-8383 Name: Date of Birth: First Middle (full) Last m/d/yr Primary care provider: Referring physician: Local Pharmacy: