McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
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1 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 list all doctors you see: Doctor s Name Type of Doctor Reason for Seeing PRESENTING CIRCUMSTANCE DESCRIBE YOUR PRESENT MEDICAL SYMPTOMS (CHIEF COMPLAINT) Why are you here? PAST MEDICAL/SURGICAL HISTORY: DO YOU HAVE ANY ONGOING ILLNESSES OR PAST MEDICAL CONDITIONS SUCH AS: YES NO YES NO YES NO Asthma Thyroid Underactive (Hypo) Angina/Chest Pain Bronchitis Thyroid Overactive (Hyper) Atrial Fibrillation Cancer (Where?) Peripheral Vascular Disease Heart Attack (MI) Kidney Failure Pain in legs with activity COPD/ Emphysema Rheumatic Fever Hepatitis A, B, or C. Stomach Ulcers Seizures Stroke/CVA/TIA Diabetes High Blood Pressure Scarlet Fever Insulin Low Blood Pressure Bleeding Problems Sleep Apnea High Cholesterol Other ILLNESSES Problem / Date of onset Problem / Date of onset Other Medical Conditions Other Cardiac Conditions Other Infectious Diseases I have had... Chicken Pox Measles Mumps Trauma (broken bones or Please list: major injuries)? SURGERIES Procedure / Date Procedure / Date - 1 -
2 (Heart Procedures) Cardiology Invasive (Arterial, Vein Procedures) Peripheral Vascular ALLERGY DO YOU HAVE ANY ALLERGIES TO DRUGS OR FOOD: YES NO Allergy To and Reaction Allergy To and Reaction MEDICATION Please list your medications here or bring a separate list indicating each medication by name, how much you take (dosage), how often you take it (once a day or more?), and who prescribed it. List all Medications: Medication Name Dosage How often taken? Who Prescribed? FAMILY MEDICAL HISTORY Father Mother Brothers Age IF LIVING Health IF DECEASED Age at Death Cause Sisters Any other family history of cardiovascular disease, strokes, diabetes or cancer? Please explain: SOCIAL HISTORY AND LIFESTYLE: - 2 -
3 How many alcoholic beverages ( beer, wine, or liquor) do you drink on an average day? Do you currently smoke Yes No If yes, what do you smoke? cigarette cigar pipe chewing tobacco. How long have you been smoking? If you quit smoking, when did you quit? How many packs per day do or did you smoke? Are you on a special diet? Yes No If yes, what type of diet? How many cups of caffeinated beverages do you drink on an average day? Do you exercise on a regular basis? Yes No If yes, what kind of exercise? Do you have a history of drug dependency? Yes No If yes, specify Are you: Single Married Divorced Widowed How many children do you have? What was the highest grade of formal education that you finished? Current or previous occupation Retired: Yes No If you currently work, how many hours per week does it involve? Any heavy physical exertion while working? Yes No If yes, what types of things? REVIEW OF SYSTEMS GENERAL: YES NO Change in exercise tolerance? Increased or Decreased Fatigue? Weight Change? Gain or Loss How much? Period of time? Change in Appetite? INTEGUMENTARY (SKIN): YES NO Changes in moles? Rash? Location of rash: Itching? Location of itching: Changes in hair? Changes in nails? EYES: YES NO Do you wear glasses/contacts? Do you have blurred vision? Do you experience double vision? Do you have a history of cataracts? Glaucoma? Have you experienced visual field loss? Do you have macular degeneration? EARS, NOSE and THROAT: YES NO Do you have a hearing deficit? Dizziness with changing position? Chronic sinus problems? - 3 -
4 EARS, NOSE and THROAT: (continued) YES NO Do you have nosebleeds? Do you wear dentures? Hoarseness/Change in voice? RESPIRATORY: (Lungs) YES NO Do you have a chronic cough? Is it Productive? Yes No Have you coughed up blood? Do you experience shortness of breath? At rest? or With Activity? Do you wheeze? Do you snore? CARDIOVASCULAR: (Heart) YES NO Chest pain pressure tightness or heaviness? At rest? or With activity? Heart palpitations: skipping fluttering racing Irregular heart beats? Short of breath lying flat? How many pillows do you sleep on at night? Wake up panicky and/or short of breath? Have you passed out? Swelling of feet or ankles? Pain in legs with walking? Describe distance before pain develops: Varicose veins? Non-healing sores on legs or feet? History of blood clots or phlebitis? GASTROINTESTINAL SYSTEM: (Stomach) YES NO Frequent nausea? Frequent heartburn? If yes, is it before or after meals? Frequent vomiting? Frequent diarrhea? Problems with constipation? Blood in Stool? Gallbladder problems? Liver Problems? GENITOURINARY: (Urinary) YES NO Do you have pain with urination? Blood in urine? Sense of urgency to urinate? Awaken frequently to urinate? History of bladder or kidney infection? History of kidney stones? Males: Prostate problems? Females: Post menopausal? If yes, are you on hormone replacement? Yes No GYNECOLOGICAL SYSTEM (Women Only) Number of pregnancies? Number of deliveries? Date of last Pap Test? Was last pap test normal? Yes No Date of last menstrual period? - 4 -
5 MUSCULOSKELETAL: (Muscle and Bone) YES NO Chronic back pain? Arthritis? Osteo or Rheumatoid History of Gout? History of blood clots in legs? History of vein ligation or stripping? Fibromyalgia? NEUROLOGICAL: YES NO Temporary blurred vision or loss of vision? If yes, which eye Right Left Temporary numbness tingling weakness of arm? If yes, which arm Right Left Temporary numbness tingling weakness of leg? If yes, which leg Right Left Fainting? Severe Headaches? Migraine Headaches? Convulsions/Seizures? PSYCHIATRIC: (Mental Health) YES NO Do you have a history of depression? Do you have chronic anxiety? ENDOCRINE: YES NO High Cholesterol? Diabetes? Thyroid Problems? HEMATOLOGICAL/IMMUNOLOGIC: YES NO Chronic low blood count/anemia? Bleeding problems? Seasonal Allergies? Latex Allergy? SLEEP HISTORY: YES NO Daytime sleepiness and/or excessive fatigue? Loud or irregular snoring? Been told that you hold your breath when you sleep? Wake up and find it difficult to catch your breath? Have restless sleep? Wake up with headaches on a regular basis? Do you choke at night? Extremity jerking during sleep? Wake up with acid-like taste in your mouth? Use CPAP or BIPAP Have CPAP or BIPAP but do not use? - 5 -
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725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
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:
NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely Date: email address: First name: Middle: Last: Nickname: Ethnicity/Race (please circle): Black or African American Caucasian Hispanic
Please describe, in detail, when the symptoms began:
161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading