SAMIR PATEL, MD. Patient Medical History
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- Pearl Tucker
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1 SAMIR PATEL, MD 285 Governor St, Providence RI Tel: (401) Fax: (425) Today s Date / / Patient Name: Who referred you to this practice? Describe briefly your present problem(s)/symptoms: Please provide details regarding any outpatient psychiatric treatment/psychotherapy you may have had for the same problem(s) or other problems in the past: Are you currently in treatment with a mental health professional? Psychiatric Hospitalizations (include where, when, for what reason & psychiatric diagnosis) Have you ever had ECT? If yes, when and for what reason?
2 CURRENT MEDICATIONS Known Drug Allergies? Yes No If yes, to what? Please list any medications that you are currently taking. Also, include non-prescription medications, vitamins, supplements, and herbal remedies. Name of the Drug Dose (strength) How do you take it? (e.g 2 tabs once daily/ 1 tab three times a day) How long have you taken the drug? 2
3 PAST MEDICAL HISTORY Do you now or have you ever had: Diabetes High Blood Pressure High Cholesterol Thyroid Problems (hypothyroidism, goiter, Grave s Disease, etc) Health Problems (Heart Attack, Coronary Bypass, Coronary Stenting, etc) Heart Rhythm Problems (arrhythmias) Heart Murmur Malignancy (Cancer/leukemia) (type): Sleep Apnea Stroke or Mini strokes chronic bronchitis) Chronic headaches (e.g. migraine) Epilepsy (seizures) Frequent Falls Parkinson s Disease Lupus or other autoimmune conditions (e.g. Rheumatoid Arthritis, Psoriasis) Rheumatic fever Arthritis Glaucoma Stomach or peptic ulcer Irritable Bowel Colitis or Crohn s Disease Asthma COPD (emphysema or chronic bronchitis) Pulmonary embolism Anemia Jaundice Hepatitis HIV/AIDS Tuberculosis Kidney Disease Other Medical Conditions (please list): PERSONAL HISTORY Were there problems with your birth? Where were you born and raised? What is your highest education? Marital Status: Religious preference, if any What is your current or past occupation? Are you currently working? If yes, hours/week If not, are you: Retired Disabled Sick Leave Do you receive disability or SSI? Yes No If yes, for how long? Have you ever had legal problems? (specify) 3
4 FAMILY HISTORY Age, if living otherwise age of death, Medical and Psychiatric Problems Father Mother Siblings Children Extended Family Psychiatric Problems: Maternal Relatives Paternal Relatives Did anyone attempt or commit suicide in your family? SYSTEMS REVIEW In the past month, have you had any of the following problems? Constitutional Recent weight gain, how much Recent weight loss, how much Fever Fatigue/Malaise/Low energy Night sweats Nervous system Headaches Tingling and Numbness Fainting/Loss of consciousness Dizziness Gait changes/falls Memory Loss Eyes Vision loss Eye pain or redness Dry eyes Double/blurry vision Blood Easy bruising/bleeding Clots Stomach/Gut/Bowel Heartburn Nausea/vomitting Blood in vomit Blood in stool Black tar-like stool Increasing constipation Persistent diarrhea Stomach aches Muscles/Joints/Bones Joint pain/stiffness: where? Bone pain Pain in muscles Jaw pain Female reproductive Irregular periods Heavy periods No periods Abnormal pap smears Menopausal hot flashes 4
5 Ears Hearing loss Ringing in ears Ear pain Throat Difficulty swallowing Frequent sore throat Hoarseness Heart and lungs Chest pains Shortness of breath Rapid heart beat Palpitations Cough/sputum Swollen legs Fainting spells Skin/Nails Rash Redness Jaundice/yellowing Changes in nail shape/texture Blisters/bumps/nodules Kidney/Genital/Urinary System Frequent urinations Burning urination Blood in urine Incontinence Discharge from penis/vagina Psychiatric Depression Loss of pleasure Stress Excessive worrying Problems falling or staying asleep Loss of appetite Loss of interest in sex/sexual problems Excessive eating/food cravings Frequent crying Guilty thoughts Poor concentration Suicidal thoughts Scary or intrusive thoughts Compulsive behaviors Violent thoughts Hallucinations Excessive energy/restlessness Rapid speech Increased impulsivity/reckless behavior Paranoia Mood swings/emotional sensitivity Irritability/rage Other symptoms WOMEN S REPRODUCTIVE HISTORY Are you currently pregnant? Maybe or planning to Do you have regular periods? Have you reached menopause? At what age? Number of pregnancies: Number of miscarriages: Number of abortions: 5
6 HISTORY OF SUBSTANCE USE Drug Category (circle each substance used) Age when first used this? How many years did you use this?? When did you last use this? Are you currently using this? Alcohol Cigarettes/tobacco product Marijuana (joint, hashish, oil, edibles, other forms ) Synthetic Marijuana (Spice, K2, etc) Stimulants without prescriptions ( Ritalin, Adderall, Dexedrine etc) Cocaine, Crack Crystal Meth, Ice, Speed Benzos (Valium, Xanax, Ativan, Klonopin, roofies, etc ) Sedatives/Barbiturates (Amytal, Seconal, etc) Painkillers (oxycodone, methadone, vicodin, percodan, morphine, codeine, etc) Heroin (snorted, injected) Hallucinogens (LSD, PCP, Special K, mescaline, peyote, mushrooms, ecstasy) Inhalants (Glue, gasoline, aerosols, paint thinner, poppers, etc) Other: 6
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Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for
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PATIENT HISTORY RECORD FACULTY INTERNAL MEDICINE Date of Appt: / / Name: Date of Birth: / / Last First Middle The information you provide today is very important in regards to your healthcare. Please answer
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
PATIENT REGISTRATION PATIENT NAME: DOB: SS#: CITY: STATE: ZIP: CELL PHONE: EMPLOYER: EMPLOYER PHONE: ( ) EMERGENCY CONTACT PH# ( ) RELATIONSHIP:
PATIENT NAME: DOB: SS#: NAME OF PARENTS (if patient is a minor) PATIENT REGISTRATION HOME ADDRESS HOME PHONE: CITY: STATE: ZIP: CELL PHONE: MAILING ADDRESS (if different) CITY: STATE: ZIP: EMPLOYER: EMPLOYER
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
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
Adult Health History New Patient
Adult Health History New Patient Today s Date PREFERRED NAME DATE OF BIRTH Reason for visit: What are your health goals for the next year? Previous Primary care Provider? Last visit? Specialists (Past