9631 N Nevada St. Suite 210. Spokane, WA Phone: (509) and Fax: (877) Jeffrey R. Jamison, D.O. and Mark J Erwin, PA-C
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1 9631 N Nevada St. Suite 210 Spkane, WA Phne: (509) and Fax: (877) Jeffrey R. Jamisn, D.O. and Mark J Erwin, PA-C Yu are scheduled fr a medical examinatin with n. The fllwing instructins will help assure accurate results. 1. Please allw 1 hur fr yur appintment. Yu will have any necessary lab wrk dne which may include an EKG and/r chest x-ray. 2. N alchl fr 72 hurs befre yur appintment. 3. D nt have anything by muth after 7pm the night befre yur appintment. This includes mints and gum. Yu can drink water. 4. If yu are n medicatins, please take them as prescribed. If fd is required, eat a small amunt. 5. Wmen: d nt duche fr 72 hurs befre yur exam. 6. Please cmplete the enclsed persnal histry frm and bring it in with yu. 7. If yu have any questins regarding these instructins, please feel free t call ur ffice. If yu are unable t keep yur appintment, please prvide 24 hurs ntice. Please nte: Yur Annual Physical Examinatin will be a health review and will cncentrate n preventative medicine. Please schedule a separate appintment fr specific cnditins r illness cncerns yu may have.
2 9631 N Nevada St. Suite 210 Spkane, WA Phne: (509) and Fax: (877) Jeffrey R. Jamisn, D.O. and Mark J Erwin, PA-C PLEASE BRING THIS FORM WITH YOU TO YOUR APPOINTMENT. PATIENT PERSONAL HISTORY FORM Name: Age: Date: Birth Date: Place f Birth: Occupatin: Dctr: Date f last physical exam: List all states and cuntries yu have lived:
3 9631 N Nevada St. Suite 210 Spkane, WA Phne: (509) and Fax: (877) Jeffrey R. Jamisn, D.O. and Mark J Erwin, PA-C Dear Patient, Yu have requested an annual physical appintment with yur dctr. An annual physical can range frm $300-$500 depending n the number f tests run. Mst insurances will allw an annual physical exam. The benefits may be limited n what yur plan may cver. A rutine wellness physical (annual physical) is an examinatin that may include an array f lab tests, chest x-ray, and EKG t test current medical cnditins, as well as t screen fr undetected prblems. Wellness physicals are nt diagnstic exams. Please cntact yur insurance cmpany prir t yur appintment t check yur benefits fr this exam as well as any limitatins that may apply t lab testing. Please nte the frnt desk cannt cntact yur insurance and are nt able t determine the cst f yur visit r what yur insurance plan will allw. It is imprtant fr yu t understand yur benefits in rder t request the apprpriate service frm yur prvider. Once a service has been rendered, it is fraudulent fr us t change the chart nte in rder t supprt a change in charges. Therefre, we WILL NOT change and re-bill charges nce they are rendered.
4 Review f Systems Allergic/Immunlgic Frequent Sneezing Hives Itching Runny Nse Sinus Pressure Cardivascular Arm pain n exertin Chest pain n exertin Chest Heaviness/ Pressure n exertin Irregular Heartbeats (Palpitatins) Knwn Heart Murmur Light headed n standing Shrtness f breath when lying dwn Shrtness f breath with walking Swelling (edema) Cnstitutinal Exercise intlerance Fatigue Fever Weight Gain ( lbs) Weight Lss ( lbs) Endcrine Eyes Fatigue Increased Thirst/ Hunger/Urinatin Difficulty getting pregnant Dry eyes Irritatin Visin Change Date f last exam Ears/Nse/Muth/Thrat Bleeding gums Difficulty hearing Dizziness Dry Muth Ear Pain Frequent clds/ sinus infectins Frequent infectins Frequent nsebleeds Harseness Muth Breathing Muth Ulcers Nse/Sinus Prblems Ringing in ears Cugh Cughing up bld Shrtness f breath Sleep Apnea Snring Wheezing Respiratry Cugh Cughing up bld Shrtness f breath Sleep Apnea Snring Wheezing Gastrintestinal Abdminal pain Black r tarry stl Bld in stl Change in appetite Frequent indigestin Hemrrhids Truble swallwing Vmiting Vmiting Bld Geniturinary Bld in Urine Difficulty Urinating
5 Incmplete emptying Increased urinary frequency Urinary lss f cntrl Erectile dysfunctin Hematlgic/Lymphatic Easy Bruising Alchl ver use Anxiety/stress Depressin D nt feel safe in relatinship Mania Sleep Prblems Histry f Addictin Swllen glands Anemia Integumentary (skin) Changes in mles Dry skin Eczema Grwth/lesins Itching Jaundice (yellwing f skin/eyes) Rash Neurlgical Dizziness Fainting Headaches Memry lss Migraines Numbness Restless legs Seizures Weakness Psychiatric
6 PATIENT NAME Date f birth Past Surgical Histry (Please include year, reasn and what hspital and/r Dctr if yu are able.): Family Histry: Please place a check in the bxes apprpriate fr yur family histry. Relatin Grandmther (M) Grandfather (M) Grandmther (P) Grandfather (P) Mther Father Brther Sister Other Alive? Age Alchlism Arthritis Depressin Cancer/type Diabetes Genetic disease Heart disease Hypertensin Osteprsis Strke Other Immunizatin Histry: Please indicate Y/N fr immunizatins yu were given and when. If unknwn, which facility wuld have them n file?
7 Chicken Px: Date: MMR (Measles, Mumps, Rubella): (Wmen Only) Obstetric and Gyneclgical Histry: Date: Flu Sht: Date: Pneumnia: Date: Gardasil/HPV: Date: Tdap(Tetanus, diphtheria, pertussis): Date: Hepatitis A: Date: Tetanus: Date: Hepatits B: Date: Zstavax/Shingles: Date: Meningcccus: Date: Other: Date: Last pap smear: Age f first perid: Number f pregnancies: Last perid/age f Menpause: Last mammgram: Number f births: Number f miscarriages: Number f cesarean sectins: Number f abrtins: Current sexual partner: Male r Female D yu use cndms? Y / N Methd f Birth Cntrl: Interested in STD screen? Y / N (Wmen Only) Circle any f the fllwing that apply t yu: Bleeding between perids Ht Flashes Heavy Perids Breast lump r nipple discharge Extreme Menstrual Pain Vaginal itching, burning r discharge Waking up in the night t use the restrm Painful intercurse Sexually Active Other Past Medical Histry: Circle any f the fllwing that apply t yu: Anxiety Disrder Diverticulitis Kidney Disease Arthritis Fibrmyalgia Kidney Stnes Asthma Gut Leg/Ft Ulcers Bleeding Disrder Has Pacemaker Liver Disease Bld Clts Heart Attack Osteprsis Cancer Heart Murmur Pli Crnary Artery Disease Hiatal Hernia r Reflux Disease Pulmnary Emblism Claustrphbia HIV r AIDS Reflux r Ulcers
8 Diabetes- Insulin High Chlesterl Strke Diabetes Nn Insulin High Bld Pressure Tuberculsis Dialysis Overactive Thyrid Other Scial Histry: Circle the fllwing that apply t yu: Educatin Marital Status Exercise Caffeine <8 th grade High Schl 2 Yr cllege 4 Yr cllege Pst Graduate Married Single Divrced Separated Widwed Dmestic Partner N Exercise Occasinal Exercise Mderate Exercise High Level Exercise Nne Occasinal Mderate Heavy # f cups per day? Alchl Tbacc Drugs Drink alchl? Y / N Hw ften? Occasinally < 3 times a week > 3 times a week # f drinks/ week? D yu use tbacc? Y / N If nt nw, did yu ever use tbacc? Y / N Cigarettes pks/day Chew /day Cigars /day # years used Or years quit D yu currently use recreatinal r street drugs? Y / N If yes, please list which nes: PATIENT NAME: Date f Birth: Additinal Health facts: (Please list ther infrmatin abut yur health yu wuld like yur Prvider t knw):
9 Patient, Parent, Guardian r Caregiver Signature Date
Patient Health History
Patient Health Histry Name: Date f Birth: Age: SS #: Tday's Date: Sex: Male Height: Female Primary Care Physician: Phne Number: Referring MD: Phne Number: Other MD's: Name/Specialty Pharmacy Name: Pharmacy
Patient Health History
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PATIENT INFORMATION. Last Name: First Name: Address: City/State/Zip: Phone: (H): (W): (C): Date of Birth: Gender: Male Female
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Patient Information Packet Date:
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Address: City: State. Phone: (Home) (Work): (Cell): Age Date of Birth / / Occupation. Referred by: Patient s condition: Duration of Problem:
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Please list any other health concerns (physical, emotional or mental) in order of importance:
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