Mercy MS Center New Patient Information
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- Baldwin Perkins
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1 Mercy MS Center New Patient Information Last Name: First Name: DOB: MULTIPLE SCLEROSIS HISTORY Reason for clinic visit: I have been diagnosed with MS or NMO (Date diagnosed ) I have not been diagnosed with MS, but may have it When did you have your FIRST symptom? What symptom(s) did you have at that time? Please list symptoms that happened next: Approx. Date Have you had attacks of symptoms that then go away (exacerbations and remissions)? Yes, No, Don t know If yes, when was your most recent exacerbation? If yes, have you had attacks that were treated with steroids? Yes, No Do you have symptoms (for example, trouble walking or fatigue) which have not gone away for a year or more? Yes, No, (For Office Use) BP HR Resp Weight Name Label Reviewed by Date
2 Medical Tests: MRI brain Most recent date: Where was it done? What was result? MRI spine Most recent date: Where was it done? What was result? Spinal Tap Most recent date: Where was it done? What was result? Other tests (Blood tests, evoked potential studies, EMG). SYMPTOMS Motor (Muscle) Symptoms How far can you walk without resting? cannot take steps at all Tremor of hands/arms 5 steps or less Difficulty writing 1 block or less Difficulty handling less than a mile eating utensils more than a mile Difficulty dressing If you had falls due to MS, how many times did you fall in the past year? Can you run? Yes No Can you climb stairs? Yes No Stiffness of legs walking Jerks / spasms Arms Legs Muscle cramps Sensory Symptoms Pain Numbness/Tingling Pain Arms Arms Legs Legs Face Face Other body area Where? Other body area Where? Electric feeling in spine with bending neck Your Name Page 2
3 Vision Loss in 1 eye Double vision Abnormal color vision Blind spots Eye pain Bowel Symptoms Urgency (can t wait) Constipation Bowel accidents Bladder Symptoms Urgency (can t wait) Bladder accidents Frequency (incl. night) Hesitancy (can t go) Bladder infections Other Symptoms Fatigue Insomnia Excessive sleepiness Memory/cognitive issues Depression Dizziness Sexual problems Heat worsens symptoms Other (specify) Other (specify) Adaptive Equipment Cane/crutch Walker used in house Walker only outside Ankle foot orthosis Manual Wheelchair Power chair/scooter Urinary catheter Sleep Problems Insomnia Snoring Nightmares Daytime sleepiness Restless leg syndrome Previous Treatments What MS Drugs do you currently take or have you taken in the past: Approximate dates: Start Ending Approximate dates: Start Ending Approximate dates: Start Ending Have you ever participated in a clinical research trial? Yes No Please tell us about the trial: Your Name Page 3
4 PAST MEDICAL HISTORY / REVIEW OF SYSTEMS Ever Ever Constitutional symptoms Genitourinary Unexplained fevers Blood in urine Unexplained weight loss Pain on urination Eye Abnormal menstrual periods Glaucoma Kidney stones Cataract Musculoskeletal Dry eyes Joint pain Serious visual disorder Back or neck pain Ear/Nose/Mouth/Throat Arthritis Hearing loss Fibromyalgia Ringing in ears Skin/breast Hoarseness Skin rash Voice change Psoriasis Trouble swallowing Breast lumps Dry mouth Breast discharge Cardiovascular Neurological Heart attack Seizure Coronary bypass surgery Stroke High blood pressure Headaches High cholesterol Head/brain injury Atrial fibrillation Psychiatric Respiratory Anxiety Cough Bipolar disease Shortness of breath Suicidal attempt(s) Asthma Hematological/Lymphatic Endocrine Problems with blood clotting Diabetes Anemia Thyroid disorder Enlarged lymph nodes Osteoporosis Leukemia / Lymphoma Gastrointestinal Liver problems ALLERGIES Ulcers Iodine (shellfish) Stomach pain Tape Crohn s or ulcerative colitis Latex Eating disorder Foods (specify): Cancer Environmental (specify): Type of cancer and year Medications (specify drug and reaction) Your Name Page 4
5 Primary doctor: Name City List other medical problems: List previous surgeries: Do you exercise? If so, what type? HABITS: Smoker: Never Previously Current packs/day for years Alcohol: Never Previously Daily Several a week Less than once a week Recreational drug use: Never Previously FAMILY HISTORY Father Living Yes No Mother Living Yes No Brother/Sister Number ( ) List Medical Illnesses Children Number ( ) SOCIAL HISTORY Marital status: Married Single Divorced Widowed Occupation: Employed outside home Homemaker Retired Student Unemployed/Between Jobs Disabled If you are receiving disability, since what year? Military Service: None Yes What branch and when? Have you been abused? No Yes Your Name Page 5
6 H CURRENT MEDICATIONS Medications: Include Prescription, Over the counter, complementary/alternative Mg or IU in each pill Taken how many times a day What local pharmacy do you prefer? What mail-in pharmacy do you use? Who is your primary physician? Please list other physicians who you would like to receive a copy of our reports? Your Name Page 6
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
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Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
Medical History Form
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Health Questionnaire
Patient Name Date of Birth Thank you for choosing Southern Cancer Center for your care. To help us best prepare for your appointment, please complete this form and bring it to your appointment. If you
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email: