PLAS/RECON SURGERY PATIENT HEALTH HISTORY
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- Gilbert Malone
- 6 years ago
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1 PLAS/RECON SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications? To Foods? 2. Are you allergic to latex? 3. Are you allergic to iodine? Medications 1. Are you taking any pain medications YES NO If so, please list all: Pain Medications Dose Times per day Reason for taking 2. All other Medications Dose Times per day Reason for taking rthwest Hospital & Medical Center University of Washington Physicians PAGE 1 OF 6
2 Social History Tobacco Use o o onevero oquito opassive Packs/day o0.25o o0.5o o1o o1.5o o2o o3o oooooo Years o0.5o 1o o2o o3o o4o o5o o10o o15o ooo o Quit O ooooo Enter Date Types ocigaretteso opipeo ocigarso osnuffo ochewo Alcohol Use o o oo Drinks/Week # Glass(es) of wine # Can(s) of beer # Shot(s) of liquor # Drink(s) with 0.5oz of alcohol Drug Use o o oo Types oamphetamines/metho oanabolic Steroidso Use/Week 1o o2o o3o o4o o5o o10o o15o oo o obenzodiazepineso ococaineo ohallucinogenso omarijuanao oopioidso oivo oinhaledo ointranasalo ooralo Other Are you currently working? o o oo What is or was your occupation? Specialty Medical History 1. Have you had any of the following (please check all that apply): Medical Problems Cancer MRSA Infection Trauma Bell s Palsy Deformity Paralysis Vascular Disease Breast Cancer Hernia Radiation Wound Dehiscence Burn Injury Keloid Skin Cancer Wound Infection Morbid Obesity Other, please specify 2. If you have or have had any other medical conditions not listed here, please specify. rthwest Hospital & Medical Center University of Washington Physicians PAGE 2 OF 6
3 General Medical History 1. Have you had any of the following (please check all that apply): Medical Problems Cardiovascular Disease Headaches Lung Disease Allergies CHF Heart Attack Musculoskeletal Anemia COPD Heart Murmur Osteoporosis Anesthesia Problem Depression Hepatitis PPD Anxiety Diabetes Type 1 HIV Seizures Arthritis Diabetes Type 2 Hypertension Stroke Asthma GERD Insomnia Substance Abuse Bleeding/Clotting Disorder GI Disease Kidney Disease Thyroid Disorder Blood Transfusion Glaucoma Lipid/Cholesterol Tuberculosis Cancer GYN Other (Please list below) 2. If you have or have had any other medical conditions not listed here, please specify. Past Surgical History 1. Have you had any of the following (please check all that apply): Pressure Ulcer Debridement Surgeries Breast Lumpectomy Facial Reconstruction Reconstruction Abdominoplasty Breast Reconstruction Free Flap Surgery Rhinoplasty Amputation Breast Surgery Hernia Repair Skin Cancer Resection Appendectomy CABG Hysterectomy Skin Grafting Blepharoplasty Carpal Tunnel Release Laparotomy Splenectomy Breast Augmentation Cholecystectomy Lymph de Surgery Weight Loss Surgery Breast Biopsy Cosmetic Surgery Mastectomy Other (Please list below) 2. Have you had any previous surgeries for this problem? o o oo Surgeries for This Problem and if they helped Surgeon Year 3. If you have had any other surgeries, please specify. rthwest Hospital & Medical Center University of Washington Physicians PAGE 3 OF 6
4 Family History Check all that apply to you and your family members PERSONAL HISTORY FAMILY HISTORY Illnesses: You Family Which family member(s) Alcohol/Drug Arthritis Asthma Birth Defects Bleeding Disorder Breast Cancer Cancer Clotting Disorder COPD Depression Diabetes Hearing Loss Heart Disease Hyperlipidemia Kidney Disease Learning Disability Lipids Mental Illness Miscarriage Obesity Ovarian Skin Cancer Other (specify): If you have other significant family history, please specify: rthwest Hospital & Medical Center University of Washington Physicians PAGE 4 OF 6
5 REVIEW OF SYSTEMS General Ear / se / Mouth / Throat Eye Neurology Heart Lung Skin Please review and check no or yes box Any current problems with your health? Comments Additional information Current Height: Weight: lbs Recent Weight gain / loss Fatigue / Trouble sleeping Fever / Chills / Night sweats Anesthesia Problems (self) Anesthesia Problems (family member) Hearing Loss / Hearing Aid Ear Problems se Problems Mouth or Throat Problems se bleeds / Sinus Problems Dental Problems / Dentures Loose or Missing Tooth / Teeth Wear glasses / contacts Eye problems Yellowing of white part of the eyes Problems with vision Headaches / Dizziness Seizures Fainting / Unconsciousness Numbness / Tingling / Weakness Chest Pain Heart Murmur High Blood Pressure Recent Heart Attack / MI Artificial Heart Valve(s) Able to walk two flights of stairs Shortness of breath (day or night) Asthma Sleep Apnea / Snoring Difficulty sleeping Lung problems Recent cold or cough Masses / Bumps / Lumps Rashes Lesions/ Cuts /Scrapes Wounds / Blisters rthwest Hospital & Medical Center University of Washington Physicians PAGE 5 OF 6
6 REVIEW OF SYSTEMS Continued Please review and check no or yes box Any current problems with your health? Comments Additional information Stomach / Gastrointestinal / Colon / Rectum Muscles / Bones Urinary Tract Male / Female Issues Reproduction Blood / Lymph Immunological Endocrine Mental Health Stomach / Abdominal pain Hiatal hernia Heartburn / Indigestion Nausea / Vomiting Diarrhea Constipation Blood in Stool Jaundice / Yellowing of skin Hepatitis A, B, or C Joint pain (where) Back pain /Disc disease Sprain / Strain Stiffness / Arthritis Artificial joint(s) Other physical disability Urinary Problems Pain with urination Kidney Problems / Kidney Stones Male or Female Specific Problems Females - Could you be pregnant? Bleeding problems Anemia Swollen or enlarged glands Hay fever Allergies HIV / Aids Heat / Cold intolerance Hyperthyroid / Hypothyroid Increased thirst / Diabetes Anxiety / Depression Psychiatric Care Other Concerns Patient Signature: Date: Provider Signature: Date & Time: rthwest Hospital & Medical Center University of Washington Physicians PAGE 6 OF 6
VASCULAR SURGERY PATIENT HEALTH HISTORY
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SURGERY SPECIALTY PATIENT HEALTH HISTORY
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All Other Medications, Dose Times per day Reason for taking the medication. Phone #
Patient Name: Date of Birth: _ Medical Record Number: Mailing Address: PO Box 29086 Thornton, CO 80229 Phone: 720.215.0700 Fax: 877.332.3131 Allergies Do you have Allergies Yes No If yes, please complete
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Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy This form must be scanned into the medical record. Do not remove from clinic. UWMC Women s Health Care Center & SCCA Women s Cancer Center
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
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
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
Who is filling out this intake form? Self Spouse Parent Guardian
Office Use Only: Reviewed with Patient Data Entry Scan & File Date: Date: Date: Initials: Initials: Initials: Today s Date: Who is filling out this intake form? Self Spouse Parent Guardian If you are not
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