PATIENT REGISTRATION INFORMATION
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1 PATIENT REGISTRATION INFORMATION Patient Name (Last, First, Middle): Social Security #: - - Age: Date of Birth: / / Sex: Male Female Language: Marital Status: Race: Ethnicity: Hispanic or Latino Not Hispanic or Latino Address: Telephone #: Cell Phone #: Address: Employer: Occupation: Employer Address: Employer Telephone #: Extension: Primary Care Physician: Telephone #: Referring Physician: Telephone #: EMERGENCY CONTACT Name: Relationship to Patient: Telephone #: Employer Telephone #:
2 GUARANTOR INFORMATION Name: Relationship to Patient: Social Security #: - - Age: Date of Birth: / / Sex: Male Female Address: Telephone #: Cell Phone #: Employer: Employer Telephone #: PRIMARY INSURANCE Insurance Name: Insurance Telephone #: ID #: Group #: Claims Mailing Address: Subscriber s Name: Relationship to Patient: Self Spouse Child Subscriber s Employer: Subscriber s Address: Subscriber s Social Security #: - - Subscriber s Date of Birth: / / SECONDARY INSURANCE Insurance Name: Insurance Telephone #: ID #: Group #: Claims Mailing Address: Subscriber s Name: Relationship to Patient: Self Spouse Child Subscriber s Employer: Subscriber s Address: Subscriber s Social Security #: - - Subscriber s Date of Birth: / /
3 MEDICAL HISTORY If Over the Age of 50, Have You Had a Colonoscopy? No Yes If Yes, When? FOR MALES ONLY: Have You Had a Prostate Exam? No Yes If Yes, When? FOR FEMALES ONLY: Have You Had a Mammogram? No Yes If Yes, When? Have You Had a Pap/Pelvic Exam? No Yes If Yes, When? Is It Possible You are Currently Pregnant? No Yes Last Menstrual Period: / / Current Contraceptive Method: # of Pregnancies: # of Live Births: 1 st Pregnancy Age: Weight Gain: 3 rd Pregnancy Age: Weight Gain: 2 nd Pregnancy Age: Weight Gain: 4 th Pregnancy Age: Weight Gain:
4 Illness/Diagnosis (please check all that apply): MEDICAL HISTORY CONTINUED Diabetes reuires insulin Diabetes reuires no insulin HIV Exposure/AIDS Thyroid Disease Insulin Resistance Irregular Menstrual Periods Morbid Obesity 5+ Years Polycystic Ovarian Syndrome Weight Gain Asthma Blood Clots-DVT Blood Clots to Lungs-PE Emphysema (COPD) Lung Disease/COPD Pneumonia Shortness of Breath w/ Activity Shortness of Breath at Rest Sleep Apnea Sleep Apnea CPAP Machine Sleeping Problems Snoring Tuberculosis Chest Pain w/ Activity (Angina) Chest Pain at Rest (Angina) Chronic Leg Sores Congestive Heart Failure Heart Attack Heart Disease Heart Palpitations High Blood Pressure High Cholesterol Irregular Heart Rate or Rhythm Leg Discoloration Leg Swelling/Edema Swelling of Ankles/Feet Aspiration/Choking Chronic Abdominal Pain Heartburn or Reflux Hiatal Hernia Nausea Nausea-Vomiting Stomach Ulcers Trouble Swallowing Ulcers/Gastritis Arthritis Chronic Back Pain Chronic Fatigue Chronic Joint Pain Chronic Headache Seizure Disorder Stroke Anxiety Bipolar Disorder Depression Low Self-Esteem Panic Attacks Drowsy Days Exercise Limitations-mild Exercise Limitationsmoderate Exercise Limitations-severe Fevers/Chills/Sweats Freuent Colds Gallbladder Attacks Gallbladder Disease Iron Deficient Anemia Skin Rash Urinary Incontinence Vitamin D Deficiency Cancer Please list any other illness/diagnosis:
5 MEDICAL HISTORY CONTINUED Physical Limitations/Disabilities (please check all that apply): Airline Travel Lifting Objects from Floor Unusual Fatigue Caring for Personal Needs Playing with Children Use of Public Seating Climbing Stairs Tying Shoes When Exposed to the Following, Do You Have Symptoms Like Red Itchy Eyes, General Itching, Shortness of Breath, Wheezing, Fast Heartbeat, Feeling Faint, Nausea or Vomiting Aspirin? Yes No Iodine? Yes No Latex? Yes No Rubber (Balloons, Band-Aids, Spandex, Tape)? Yes No Please List Any Previous Cardiac Procedures or Testing and Cardiologist Name: Illness/Diagnosis (please check all that apply): FAMILY MEDICAL HISTORY No information Diabetes Mother Father Other Morbid Obesity Mother Father Other Heart Disease Mother Father Other High Blood Pressure Mother Father Other Heart Attack Mother Father Other Asthma Mother Father Other Emphysema/COPD Mother Father Other Bowl/Colon Disease Mother Father Other Kidney Disease Mother Father Other Liver Disease Mother Father Other Bleeding Disorder Mother Father Other Cancer Mother Father Other Clotting Disorder Mother Father Other Breast Disease Mother Father Other Stroke Mother Father Other Arthritis Mother Father Other Depression/Anxiety Mother Father Other Hepatitis Mother Father Other Other: Other: Other: Other: Other: Other:
6 SURGICAL HISTORY Surgical Procedures (please check all that apply): Back/Neck Surgery Roux-N-Y Gastric Bypass Surgery to the Small Bowel Caesarean Section Sleeve Gastrectomy Surgery to the Stomach Dilation & Curettage (D&C) Surgery to the Chest or Lung Tonsillectomy Gallbladder Surgery to the Esophagus Other: Gastric Banding Surgery to the Heart Other: Hysterectomy Surgery to the Large Bowel Other: Surgical Complications (please check all that apply): Anesthesia Problems Blood Transfusion Other: Bleeding Infections Other: Please List Other Significant Conditions or Hospitalizations: NUTRITIONAL HISTORY # of Meals Per Day: Do You Eat Between Meals? Yes No # of Glasses of Water Per Day: Food Preferences (please check all that apply): Cakes/Pies Cookies Pizza Candy Dairy Products Seafood Chips/Snacks Fast Food Steak/Red Meat Chocolate Fried Food Vegetables SOCIAL HISTORY Do You Use Tobacco? No Yes If Yes, What Type? Chew Cigarettes Cigar Pipes # Per Day: # of Years If you Quit, When? Do You Drink Sodas? No Yes If Yes, What Type? Diet Regular # Per Day Do You Drink Alcoholic Beverages? No Yes Do You Drink Coffee/Caffeine? No Yes If Yes, How Many Times Per Week? If Yes, How Many Cups Per Day? Have you Ever Used Marijuana or Other Illicit Drugs? No Yes Do You Tolerate Physical Exercise? No Yes Do You Have Trouble Sleeping? No Yes
7 MEDICATIONS Please list any medication allergies: Preferred Pharmacy: Location/Address: CURRENT MEDICATIONS Medication Name Strength Freuency Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter
8 WEIGHT LOSS HISTORY Diet Year(s) Weight Lost # of Months on Program Acupuncture Behavior Modification Exercise Fen-Phen Hypnosis Injections Jenny Craig Meridia Nutritionist/Dietitian Psychiatrist/Therapy Opti-Fast Overeaters Anonymous Redux Richard Simmons Weight Watchers Xenical Physician-Directed Plan(s) List: List: Self-Monitored Diet(s) List: List:
9 Patient Name: DOB: If yes, when and where: Current use of CPAP? If you have been previously diagnosed with Obstructive Sleep Apnea and instructed to use a CPAP do you use it daily as prescribed? Do you have a personal history of any of the following? 1. Abnormal movement, behavior, emotions, or dreams while sleeping 2. Previous home sleep study which did not diagnose OSA Excessive Daytime Sleepiness 5. Insomnia? (Inability to sleep) 6. Has anyone ever told you that you stopped breathing during sleep? 7. Have you experienced gasping or choking while sleeping? 8. Do you freuently arouse during sleep? If you answered yes to any of the above symptoms, how long have you been experiencing them?
10 Do you have a personal medical history for any of the following? 9. High Blood Pressure 10. Use of three or more medications to treat High Blood Pressure 11. Any head or facial or upper airway soft tissue abnormality 12. euromuscular disease 13. Stroke in the past 30 days? 14. Mini strokes (Transient ischemic attacks (TIA)) 15. Coronary artery disease (CAD) 16. Heart Disease 17. No Fast heart rate (tachycardia) 18. Slow heart rate (bradycardia) 19. COPD/Emphysema/Lung Disease/Asthma 20. Congestive Heart Failure (CHF) Narcolepsy 23. Nocturnal Seizures 24. Use of home oxygen 25. Use of prescription narcotic pain medication *** To be filled out by clinic staff only*** BMI Neck circumference inches
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PERSONAL INFORMATION. Last Name: First Name: MI: Name of Spouse/Partner/Significant Other: Social Security Number: - - Drivers License No.
Date Form Completed / / Medical and Bariatric History The following information is very important to your health. Please take the time to fully and completely fill out this important information. PERSONAL
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Medical History. Past Medical History
Regional Surgical Associates Dr. Adam S. Goldstein Medical History Date Name Social Security Number - - DOB Age Height Weight BMI Primary care doctor For office use only Height Weight BMI Neck Goal Ideal
1960 FP CENTER FOR SLEEP DISORDERS
1960 FP CENTER FOR SLEEP DISORDERS Sleep Questionnaire Name: Date: Date of Birth: / / Age: Gender: Height: Weight: lbs. Referring Physician: Occupation: Please give a brief description of your sleep problem
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE PLEASE PRINT Full name: Age: Preferred Contact number: Email address: Why are you here today? To establish primary care Annual exam Consultation from another doctor If consultation,
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
Primary Care Physician Physician Name: Phone: Fax: Address:
Page 1 of 6 Demographics Name: _ (First, Middle Initial, Last) Date of birth: Age: Gender: Male Female Marital Status: Married Single Divorced Widowed Address: City: State: Zip Code: Home Phone: Work Phone:
PATIENT HISTORY FORM
PATIENT HISTORY FORM Date: Page 1 of 5 Last Name: First Name: Middle Initial: Referred By: Age: Primary Care Doctor: Please provide name(s) of other physician(s) that you have visited within the last year:
NAME NAME ADDRESS ADDRESS. PHONE PHONE Cell Phone DATE OF BIRTH DATE OF BIRTH OCCUPATION OCCUPATION MARITAL STATUS MARITAL STATUS
PATIENT INFORMATION (please print) SPOUSE OR PARENT INFORMATION NAME NAME _ ADDRESS ADDRESS PHONE PHONE _ Cell Phone E-MAIL _ E-MAIL DATE OF BIRTH DATE OF BIRTH OCCUPATION OCCUPATION MARITAL STATUS MARITAL
Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E mail newsletters, reminders, statements, etc. Emergency Name: Phone: City: State: Zip: Home
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
Name: DOB: Age: Weight Loss Surgery Follow-Up Data. Height Weight LB WL BMI EBW %EWL
Weight Loss Surgery Follow-Up Data Height Weight LB WL BMI EBW %EWL How many meals per day do you eat? On average, how long does it take you to eat a meal? How many times a day do you snack? How many 8oz.