Please complete this questionnaire and bring it to your first appointment.
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- Martin Hunter
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1 Please complete this questionnaire and bring it to your first appointment. Name: Date: DOB: Age: Legal Guardian if other than self Name of Person filling out form (if different than patient): What brought you to seek treatment at PrairieCare? (please include specific symptoms you are experiencing) Did someone refer you to PrairieCare? If so, who: Current and Past Psychiatric/Chemical Dependency treatments: Are you seeing or have you seen others in the past for psychiatric or chemical dependency issues? (family practitioner, inpatient or outpatient treatments, detox, etc.) If so, specify: Name: Location: Reason: Dates: 6. Other Information: Rev. 12/14 Page 1 of 9
2 Describe your typical day: Do you drink alcohol? If yes, please describe: Do you use street drugs? If yes, please describe: Do you have any concerns about your diet or eating habits? (including eating disorders) If you are having difficulties who do you go to for support? Identified Religion (if any): Are you currently active in any faith community? Yes No If so, how supportive is this to you and how active are you in this community? Medical History: Primary doctor and/or clinic: Date last seen: Rev. 12/14 Page 2 of 9
3 Would you like us to share information with this provider? No Yes (if so, please complete a release of information) Medical Hospitalizations: Where: Reason: Date: Are you currently being treated for any medical problems? If so, please list problem(s) and treatment(s). 6. Please check any current health issues that apply to you and describe: General weight appetite fatigue poor sleep Eyes blurry flashes dry pain Ears/Nose/ Mouth/Throat Cardiovascular Respiratory_ Gastrointestinal GenitoUrinary Musculoskeletal dry mouth chest pain shortness heartburn hesitancy stiffness congestion dizziness of breath nausea retention swelling headache swollen cough constipation menses aches ringing feet wheezing diarrhea sexual injury leg cramps Neurological_ Skin Endocrine Hematological Immunologic Describe checked symptoms or others not listed: movements weakness tremor seizure rash itching dry hair.loss too cold too warm sweating thirst bruising bleeding nodes anemia hives congested infections rashes None of Above Rev. 12/14 Page 3 of 9
4 Do you have any other concerns about your current health? (pain, eating, mobility etc): Current Medications: What medications are you currently taking? (include ALL medications, over the counter medications, herbal remedies, etc.) Doctor/ Current Medications When Started Prescriber Effects What psychiatric medications have you taken in the PAST, please list and describe in chronological order, if possible: Past Medications Dates/ When Tried Doctor/ Prescriber Effects *Continue on following page if necessary Rev. 12/14 Page 4 of 9
5 Past Medications Dates/ When Tried Doctor/ Prescriber Effects Allergies (please note any substances to which you are allergic and your reaction to them): Substance/Medication: Reaction: Surgeries (please note any surgical procedures you have had): Reason: Where: Date: Have you ever experienced a head injury? Yes or No. If yes, please explain Have you ever experienced a seizure? Yes No. If Yes, please explain Have you ever had meningitis or encephalitis? Yes No If so, when Have you ever been exposed to the Herpes Simplex virus? Yes No Rev. 12/14 Page 5 of 9
6 Do you smoke Yes No. If yes, how long? Amount Family Psychiatric/Chemical Dependency History: Are there any psychiatric or chemical dependency issues in your family? Yes No If yes, please describe Who: Type of Illness: Social History: Where were you raised and by whom? Who was living in the household when you were growing up? (relationship including siblings, other relatives, friends etc): Did you get in trouble as a child/adolescent? If so, please describe: Any legal issues in the past or present? If so, describe: Were you exposed to any type of abuse (sexual, physical, emotional, verbal etc)? If so, describe type, by whom, duration: Rev. 12/14 Page 6 of 9
7 Educational background: Years completed: Degrees/certificates/diplomas obtained: Did you receive any special assistance/classes in school? If so, explain: Vocational/employment history: Type of employment: Start Date: Duration: Why left? Rev. 12/14 Page 7 of 9
8 Marital Status: single married separated divorced If divorced or separated, how long? Any other significant relationships not resulting in marriage (describe when, how long): Current living situation (who lives in the household, relationship): Children (names and ages): Please list any other problems you feel are important: Rev. 12/14 Page 8 of 9
9 Please list questions you would like answered at this appointment if possible: Rev. 12/14 Page 9 of 9
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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
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Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
Patient Interview Form
Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information
Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?
Gregory H. Tchejeyan, M.D., Inc. Please fill out this form in its entirety. Please complete every line item, as it is necessitated by regulations from the government (Health Care Finance Administration
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