Patient Name: TAKING AS PRESCRIBED
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1 Patient Name: Date of Birth / / Date completing this form / / 1. Name of Family Physician: Date of Last Exam: / / 2. Do you have medical concerns at the present time? No Yes (if yes please describe): - 3. Preferred Pharmacy? 4. Please list all medications that you are currently taking, including both physicianprescribed and over-the-counter medications (aspirin, laxatives, vitamins, herbal supplements, diet pills, etc.). MEDICATION DOSAGE & DIRECTIONS TAKING AS PRESCRIBED HOW LONG HAVE YOU TAKEN? WHO PRESCRIBES? SIDE- EFFECTS? 5. Are you allergic to any medications or environmental substances (i.e. pollen, molds, etc.)? No Yes: 6. Have you had any unexpected weight gain for weight loss within the past 3 months? No Yes: 7. Do you smoke cigarettes, pipes, cigars, or chew tobacco? No Yes: 8. Are you interested in receiving Naloxone (Narcan) certification? We offer this as a part of treatment at no additional cost. 9. Family Medical History To the best of your knowledge, please put a check if you have or anyone in your family has had the following: Anemia Arthritis Asthma Cancer Dementia Diabetes Eating Disorder Emphysema Epilepsy Heart Problems Self Mother Father Brother Sister Children Grandparent Other Family Page 1 of 6
2 Irritable Bowel HIV/ AIDS Kidney Problems Mental Illness Migraines Substance Abuse Thyroid Problems 10. Are you currently receiving mental health or substance abuse treatment elsewhere? No Yes Are any of the following services or agencies currently involved in your life and/or providing you with services? Service Yes Service Yes Probation or Parole MH / MR Domestic Relations Social security CPS Other Agencies or Services? 12. Have your ever been diagnosed with the following? (Please mark yes or no) Diagnosis Yes No Diagnosis Yes No Diagnosis Yes No Cancer Tuberculosis Bleeding Disorder Heart Attack Positive TB Skin Test HIV Artery Disease Arthritis Gonorrhea/Chlamydia Rheumatic Fever Gout Syphilis Heart Murmur Rheumatoid Arthritis Herpes Heart Failure Bladder Infection s IV Drug Use High Blood Pressure Kidney Stones Migraines Stroke Kidney Disease Depression Diabetes Chicken Pox Anxiety Gallstones Infectious Mono Bipolar Liver Disease Anemia Schizophrenia Hepatitis Sinus Infections Personality Disorder Ulcer Disease Glaucoma ADD Heartburn / Reflux Thyroid Disease ADHD Asthma / COPD Head Injury Other: Seizures Broken Bones Pneumonia Blood Transfusion Page 2 of 6
3 13. Surgical history (if applies then please indicate the year): Surgery Year Surgery Year Surgery Year Eyes Gall Bladder Uterus Ears Appendix Spinal / Neck Sinus / Nasal Septum Intestine Colon Spinal / Back Tonsils / Adenoids Hemorrhoids Hip / Knee Thyroid Hernia Shoulder Heart Hysterectomy Hand / Feet Stomach Breast Other: Varicose Veins Ovaries C-Section Tubal Ligation 14. How many hospitalizations have you had and when was your last admission? 15. When was your last TB test? 16. When was your last HIV test? 17. When was your last Hepatitis C test? 18. Gynecological / Obstetrical History: a. Date of last menstrual period? b. Is there any change you are pregnant? c. Are you currently using birth control? d. Number of pregnancies? e. Number of live births? f. Any complications during birth? Page 3 of 6
4 19. Have you experienced the following in the last week? General Yes No Gastrointestinal Yes No Skin Yes No Fatigue Abdominal Pain Rash Fever Constipation New Lesions Weight Gain Diarrhea Nail Changes Weight Loss Nausea Change in Moles Trouble Sleeping Vomiting Inj. Site Redness Rectal Bleeding Inj. Site Discharge HEENT Yes No Change in Bowel Habits Inj. Site Swelling Double Vision Blood in Stools Blurry Vision Dark Tarry Stools Neurological Yes No Eye Redness Seizures Eye Pain Genitourinary Yes No Tremors Eye Drainage Painful Urination Numbness/Tingling Decreased Hearing Change in Urinary Stream Memory Issues Ringing in Ears Increased Urination Trouble Focusing Ear Drainage Loss of Bladder Difficulty Concentrating Ear Pain Night time Urination Paralysis Nose Bleeds Trouble Urinating Loss of Bowel Control Sore Throat Flank Paint Loss of Bladder Control Trouble Swallowing Penile Discharge Oral Ulcers Testicular Pain Psychiatric Yes No Bleeding Gums Testicular Mass Anxiety Broken Teeth Groin Pain Depression Active Cavities Swollen Glands Racing Thoughts Headaches Suicidal Thoughts Dizziness OB-GYN History Yes No Suicide Attempts Breast Mass Neck Yes No Breast Pain Endocrine Yes No Neck Pain Deformities Appetite Changes Swollen Glands Nipple Discharge Cold Intolerance Skin Changes Increased Thirst Respiratory Yes No Vaginal Discharge Increased Urination Ongoing Cough Irregular Periods Difficulty Breathing Hematology Coughing up Blood Musculoskeletal Yes No Easy Bruising Wheezing Joint Pain Enlarged Lymph node Joint Swelling Prolonged Bleeding Cardiovascular Yes No Joint Deformities Chest Paint Joint Redness Leg Pain with Walking Joint Stiffness Decreased Exercise Tolerance Muscle Aches Shortness of Breath Muscle Weakness Trouble Sleeping Due to Difficulty Breathing Back Pain Leg Swelling Page 4 of 6
5 Vocational Status I am presently: (Please mark with an X ) Employed Full-Time Employed Part-Time Assigned Temporary Work Unemployed Laid Off Disabled / On Disability Retired Student On Leave-Of-Absence If employed, please provide the occupation: Please place an X in any of the following that are currently problems for you: Family Problems (i.e. death of family member, health problems in family, lack of social support, isolated from others, discrimination, do not get along well with others, etc.) Social/Friendship Problems (i.e. death or loss of friend, lack of social support, isolated from others, discrimination, do not get along well with others, etc.) Job or School Problems (i.e. unemployment, stressful schedule, poor work, school conditions, job dissatisfaction, do not get along with boss/teachers/coworkers/classmates, etc.) Housing Problems (i.e. homeless, poor housing conditions, unsafe neighborhood, problems with neighbors, problems with landlord, etc.) Money Problems (i.e. cannot pay bills, not enough money for basic necessities like food, shelter, clothing, excessive debt, bankruptcy, etc.) Problems with Health Care (i.e. do not have a doctor, do not have a way to get to appointments, do not have health insurance, cannot obtain needed medications, etc.) Legal Problems (i.e. involved in court, on probation or parole, victim of a crime, pending lawsuit, DUI, etc.) Gambling Problems (i.e. lack of control, being deceptive about the amount spent or frequency of gambling, etc.) Page 5 of 6
6 Patient Name DOB: / / Ethnic Origin: Cuban Hispanic or Latino Mexican Not of Hispanic Origin Puerto Rican Marital Status: Divorced Life Partner Married Never Married Separated Unknown Widowed Race: American Indian or Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander Other Unknown White SSN: Please choose 3 out of 5 questions: 1. What is your mother s maiden name? 2. What is your favorite color? 3. What is your fahter s middle name? 4. What is your favorite TV show? 5. What is the name of the street you great up on? Page 6 of 6
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Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM DATE: PATIENT INFORMATION (PLEASE USE FULL LEGAL NAME, NO NICKNAMES) LAST NAME: FIRST NAME: MI: ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK PHONE: E-MAIL ADDRESS:
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
Past Medical History. Chief Complaint: Appointment Date: Page 1
Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty
Psychiatric Evaluation Intake Form
Patient Contact Information Psychiatric Evaluation Intake Form Patient Name: Date of Birth: Age: Last First MI Address: Contact phone number: Email address: Emergency Contact/Number/Relationship: Primary
Patient Interview Form
Patient Interview Form Patient Information First Name: Last Name: Date of Birth: Age: Email Personal: Race Select one or more Referring Physician White Black or African Asian American Indian Native Hawaiian
DNA CENTER New Patient Information
DNA CENTER New Patient Information Name Email: Address City State Zip Home Phone Work Cell Phone Social Security Number Date of birth Gender ( Male/Female) Age Please Circle: Hispanic/Latin or Non Hispanic/Latin
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency.
GENERAL SURGICAL ASSOCIATES A practice of Lehigh Valley Physician Group Suite 208 ~ 1240 S. Cedar Crest Boulevard ~ Allentown, PA 18103 Phone: (610) 402-9780 PLEASE COMPLETE THIS FORM PRIOR TO YOUR VISIST
Patient Interview Form
Page 1 of 6 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Race Select
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:
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints