Review of Systems. Name: Date of birth: Today s Date:
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1 1 Review of Systems Name: Date of birth: Today s Date: YOUR HEALTHCARE TEAM Please list all healthcare practitioners you are currently being treated by: Name Type of practitioner (eg. family doctor, counselor, acupuncturist, RMT) Phone and fax number Phone: Fax Phone: Fax: Phone: Fax: Please List your chief complaints in order of importance: 1) 2) 3) 4) Additional comments about chief complaints: MEDICATION YOU ARE CURRENTLY TAKING Name/ brand/ type Dose For what condition Since when
2 2 PAST MEDICATION Name/ brand/ type Dose For what condition For how long? NATURAL HEALTH PRODUCTS YOU ARE CURRENTLY TAKING Product/ brand Dose Reason Since when MEDICAL HISTORY Have you ever been hospitalized/ had surgery? Date: Reason Problems experienced since For each of the following items, please write (N) for conditions you have never experienced, (P) for conditions you have experienced in the past or (C) for conditions you are currently experiencing. Where several conditions are listed together please circle the condition that pertains to you. SKIN Rashes/ eczema/ hives/ itching Hair changes (colour, shine, loss) Acne/ boils/ bumps/ lumps Temperature Excess dryness/ moistness Night sweats Colour change/ mole changes Skin ulcers Nail changes (shape, strength, thickness) Skin cancer Have you ever had a complete skin exam? Date: HEAD Headache Problems with jaw joint? (TMJ) Head injury Dizziness Have you ever had an MRI, CT Scan etc? Date: Result: EYES Impaired vision/ double vision/ blurring Floaters Glasses/ contact lenses Sensitive to sunlight Eye pain Itching/ discharge Excess tearing/ dryness Blindspot Glaucoma/ cataracts Redness When did you last visit your eye doctor? Do you use eyedrops, artificial tears or other eye products?
3 3 Ringing Impaired hearing/ hearing aid Earache/ Infection Ear tubes Frequent colds/ stuffiness Nose bleeds Allergies/ hay fever Frequent sore throat/ hoarseness Sore tongue/ mouth Gum problems/ bleeding Dry mouth Dental cavities When was your last visit to the dentist? EARS Discharge Excess ear wax Ruptured ear drum Do you use Q-tips? NOSE AND SINUSES Sinus problems Sensitive to smells Change in ability to taste MOUTH, THROAT AND NECK Lumps/ swollen glands in neck Thyroid problems/ goiter Pain/ stiffness in neck How many? What type of filling? How often do you brush? How often do you floss? RESPIRATORY Cough/ wheezing Shortness of breath when lying down Sputum/ mucous Bronchitis Spitting up blood Pneumonia Asthma Pleurisy (inflammation of lungs) Pain/ difficulty on breathing Emphysema Shortness of breath Tuberculosis Shortness of breath at night/ apnea Do you smoke? How long? How many? Tuberculin test Date: Test result: Date of last chest x-ray CARDIOVASCULAR Heart disease High blood cholesterol Angina/ chest pain Rheumatic fever High blood pressure Swelling in ankles Murmur/ irregular heart beat/ palpitations/ Cyanosis (blueness) fluttering Past ECG Date: Result: Other heart tests/ stress test BREASTS Lumps/ skin puckering Nipple discharge/ changes Pain or tenderness Implants/ reduction/ surgery Have you ever breast fed? Any problems breast feeding? Do you do self exams? How often? Is there is history of breast cancer in your family? Heartburn/ acid reflux Trouble swallowing Changes in appetite/ thirst GASTROINTESTINAL Belching/ passing gas Offensive breath/ bad taste in mouth Bloating/ abdominal pain
4 4 Nausea/ vomiting Vomiting blood How often are your bowel movements? Blood/ mucous/ undigested food in stool Liver disease/ hepatitis Gall bladder disease/ stones/ removal Ulcer Food allergies/ sensitivities Yellow skin Hernia Is this a change? Indigestion Diarrhea/ constipation Rectal bleeding/ hemorrhoids Black tarry stool Please list offending foods: How is your appetite? a) I m hungry all the time and can t seem to satisfy my hunger (regular meals aren t enough) b) It seems normal to me (eat regular meals) c) I m not often hungry and I sometimes have to force myself to eat (can easily skip meals) How is your thirst? a) I ve noticed an increased thirst that I can t satisfy (drink a lot of fluids throughout the day) b) It seems normal to me (drink fluids throughout the day) c) I m not usually thirsty (I forget to drink fluids) What food restrictions do you have? Do you have any food cravings? Please list the foods that you crave most: What affects your food cravings? How much water do you drink? (do not include caffeinated drinks or alcohol) Do you drink tea, coffee, or pop? How much? Do you drink alcohol? What kind? How much? 24 hour food recall: Please write down what you typically eat in a day (include time and amounts): Have you had any gastrointestinal surgeries? Do you take antacids/ special digestive aids? Is there a history of colorectal cancer in you family? URINARY Pain/ pressure on urination Inability to hold urine/ incontinent Blood in urine Frequent urinary infections Increased frequency Kidney problems (stones, infections) Frequency at night Urgency/ hesitancy MALE REPRODUCTIVE Testicular masses/ pain Prostate problems Do you do testicular self-exams?
5 5 When was last prostate exam? Any sexual difficulties/ erectile dysfunction Discharge/ sores Problems with sperm/ conceiving FEMALE REPRODUCTIVE Age of first period Average number of days of bleeding Length of cycle Bleeding between periods PMS/ painful periods Irregular cycles Excess flow Sexual difficulties/ pain during intercourse Hormonal birth control Number of pregnancies Number of miscarriages/ abortions Number of live births Difficulties conceiving Menopause Age: Hot flashes/ dryness/ other problems with Cervical cancer menopause Hormonal therapy for menopause Vaginal itching/ redness Vaginal discharge (circle those that apply) a) clear fluid b) white c) thick or sticky d) greenish/ yellow e) grey f) strong odour (fishy) Date of last PAP Sexually transmitted disease(s) Result MALE AND FEMALE SEXUAL Since when? Joint pain or stiffness/ swelling Bone fractures Muscle spasms/ cramps History of injury/ accidents MUSCULOSKELETAL Muscle weakness Back pain Arthritis Have you ever had a bone density test? PERIPHERAL VASCULAR Cold hands/ feet Vein pain (thrombophlebitis) Varicose veins Extremity numbness/ swelling/ pain/ ulcers Deep leg pain/ leg cramps NEUROLOGIC Fainting Loss of balance Seizures/ convulsions Speech problems/ slurring Paralysis Involuntary movement Numbness or tingling Loss of memory ENDOCRINE Sensitive to heat or cold Diabetes Thyroid problems Hypoglycemia (low blood sugar)
6 6 Excessive thirst/ hunger Excessive urination/ sweating Anemia Easy bleeding/ bruising Blood transfusions What is your blood type? Any reactions to vaccines? Drug sensitivities Please list all allergies Hormone/ steroid therapy BLOOD/ LYMPHATIC Lymph node swelling Hemophilia When? ALLERGIES MENTAL EMOTIONAL Mood swings Depression Sleeping difficulties/ insomnia Phobia Anxiety Excess stress Have you experienced past trauma/ significant grief? Are you still affected by it today? Substance abuse Have you been treated for substance abuse? Thoughts of suicides/ attempts Have you ever sought help or used medication to deal with personal problems? SLEEP How many hours do you usually sleep? How many hours of sleep do you need? Do you awake well rested? Do you take naps during the day? Do you fall asleep during the day? Do you talk/ walk in your sleep? Grind teeth while sleeping Have vivid dreams Sleep apnea Shift work Do you take medication or other substances to help you sleep? ENERGY How is your energy? (please choose one) a) I have plenty of energy for work and for all my daily activities b) I have enough energy during work, but feel tired for the rest of the day c) I don t have enough energy for work or any other activities What affects your energy level? EXERCISE How would you describe your daily activity level? a) very active b) moderately active c) sedentary Do you exercise regularly? What kind? How frequently? How long?
7 7 FAMILY MEDICAL HISTORY Has anyone in your family (siblings, parents, Which member was affected by this grandparents) had the following conditions? condition Heart disease High blood pressure Diabetes/ blood sugar problems Asthma Allergies Cancer (breast, colon, lung, liver, skin, prostate etc) Psychiatric (depression, anxiety, addiction etc) Kidney problems Hormonal problems (thyroid, pituitary, estrogen, testosterone, adrenal (cortisol) etc) Congenital (birth)/ developmental problem Neurologic problems (eg. MS, parkinson s, Alzeimer s) Arthritis Other Age Additional comments: Thank you for investing time and energy in your health. I look forward to working with you on this journey to better health and wellness, Dr Marlene Senaratne, BSc(Hon), ND.
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Naturopathic Medicine Intake Form Adults (16+) Name: Date of birth: Gender: Address: City: Postal Code: Home Phone: Mobile/Work: Email: Marital status: Spouse/Partner s name: Emergency Contact: Phone Number:
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
Condition #2: What is the next important condition you would like help with, and how long ago did it begin?:
NAME _ Please take the time to fill this form out completely. The more information we have, the better we can assist you, and will make better use of your initial visit. What is the main problem you would
Patient First Name Patient Middle Initial Patient Last Name. Primary Care Physician Primary Care Physician Phone Pharmacy Name
NP Hagans Walk-In Clinic * 9135 Piscataway Rd. # 320 Clinton, MD 20735 * (240)-412-5093 (Office) Patient Information Patient First Patient Middle Initial Patient Last Sex Marital Status Date of Birth Social
Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us?
Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): Email address: Occupation: Who referred you/how did you hear about us? Your primary health care provider: Phone: Emergency
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
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The Rehabilitation Institute Cancer Rehabilitation
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Patient Intake Form for Allegany Ear, Nose, & Throat
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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 Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
Health History. Tests and Procedures: Test: Date: Location: Provider: Abnormal: Results/Notes: Monthly self breast exam. Last mammogram (female)
Comprehensive Cancer Center A Cancer Center Designated by the National Cancer Institute Please answer the following questions and bring this form to your first appointment at Rutgers Cancer Institute of
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
Health History Questionnaire Date: / /.
Health History Questionnaire : / /. Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: of Birth: Place of Birth: Height : Weight: Employer: Relationship Status: Occupation:
I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION
PERSONAL INFORMATION NAME: TODAY'S DATE: ADDRESS HEIGHT: WEIGHT: DATE OF BIRTH: AGE: GENDER: PHONE: HOME MOBILE WORK EMAIL ADDRESS: EMERGENCY CONTACT: STATUS: SINGLE MARRIED DIVORCED WIDOWED OTHER: NUMBER
NEW PATIENT INFORMATION FORM
UNIT NUMBER PT. NAME UCSF Medical Center AMBULATORY SERVICES BIRTHDATE LOCATION DATE Today s Date / / What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician
Oriental Medicine Questionnaire
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