3400-C Old Milton Parkway, Suite Northside Forsyth Drive, Suite 3400 Alpharetta, GA Cumming, GA 30042
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1 3400-C Old Milton Parkway, Suite Northside Forsyth Drive, Suite 3400 Alpharetta, GA Cumming, GA Phone: Fax: Welcome to our practice! On behalf of North Point Pulmonary Associates, we welcome and thank you for choosing our practice. It is our desire to make your visit a pleasant one and to work with you to establish a positive treatment plan. Please expect to be with us for a minimum of two (2) hours; we may need to take x-rays, perform Pulmonary Function Testing and Spirometry to accurately diagnose and treat your condition. Please help us provide the best medical care by bringing the following required items: All of your medications. If you are unable to bring the bottles, please bring a list of medications, the dosage, and the number of times taken daily, including all over-the-counter medications. Medical records from referring physician Current X-Ray and CT/MRI Studies (Please bring film, report, and CD disc) Hospital or lab reports that may be pertinent to your first visit Completed History and Demographic forms Insurance Card Photo Identification Insurance Referral from your primary care physician We request all History and Demographic documents be completed prior to your appointment and ask that you arrive 30 minutes early. If documents aren t completed, we will need to reschedule your appointment. Thank you for your assistance and we look forward to meeting you! Dr. Daniel Callahan Dr. Gayle Mason Michael Rayburn, PA-C
2 Patient Name Date of Birth Past Medical History Please list any medical conditions that you have been diagnosed with: MEDICAL CONDITION DATE DIAGNOSED TREATING PHYSICIAN Please list any Surgeries and hospitalizations you ve ever had. Surgery Hospitalization/Reason Date(s) NPP028 Piedmont Graphics Rev. 01/05/16
3 Please check all that apply: Cancer (Indicate Type) Respiratory Disease Mental Illness High Blood Pressure Kidney Disease Diabetes Heart Disease Blood Clot Tuberculosis Other: Other: Family History MOTHER FATHER SIBLING GRANDPARENT AUNT/UNCLE AGE OF DEATH: Mother Father Siblings Grandparents Social History (please check one) Single Married Divorced Widowed Domestic Partner Have you ever had x-ray dye? YES/NO Allergic to x-ray dye? YES/NO Have you ever smoked? YES/NO How many packs per day? For how many years? If you no longer smoke, when did you quit? Do you consume alcohol? Currently In the past Never If currently how much? Do you or have you ever used recreational drugs? Do you exercise? How often? Have you ever used diet pills? Medication Last time taken: Patient Name Date of Birth Are you exposed to any pets? dogs, cats, birds, rodents or wild animals YES/NO Describe Have you ever worked in/with? MINE BRICK PLANT FOUNDRY QUARRY POTTERY COTTON/FLAX/HEMP/MILL NONE Have you ever been exposed to? ASBESTOS BERYLLIUM ACIDS LEAD SOLVENTS COAL DUST GRINDING DUST NONE Have you ever served in the military? YES/NO What Branch? Dates of Service? Have you ever lived in any of the following areas? (please circle) ARIZONA, CALIFORNIA, OHIO VALLEY any other SOUTHERN STATES NPP014 Piedmont Graphics Rev. 11/20/15
4 Patient Name: North Point Pulmonary Associates 3400 Old Milton Parkway Building C Suite 425 Alpharetta, GA Phone: Fax: PATIENT HEALTH SUMMARY Patient DOB: Date of last Flu Vaccine: ALLERGIES: VACCINE INFORMATION Date of last Pneumonia Vaccine: DATE (diagnosed) PAST MEDICAL HISTORY DATE (surgery date) PAST SURGICAL HISTORY STAFF INITIALS INITALLY COMPLETED BY: Employee NPP013 Piedmont Graphics Rev. 11/16/15 Date
5 Review of Systems Welcome, so that we may provide you with the best care possible, please assist us by completing the following form. Remember always bring an updated list of all your medications including inhalers. Please mark all that apply: GENERAL Fevers Night Sweats Fatigue Appetite Loss Recent weight Changes EYES Glaucoma Cataracts Macular Degeneration EAR/NOSE/THROAT Nasal Congestion Postnasal Drip Voice Hoarseness Sinus Disease Seasonal Allergies CARDIAC Heart Attack (MI) Valvular Heart Disease Heart Murmur Rheumatic Fever Abnormal Cholesterol Congenital Heart Defect Hypertension Palpitations Heart Rhythm Disorder Pacemaker or Cardiac Defibrillator (ICD) Claudication/Leg Pains Passing out/syncope RESPIRATORY Dry Cough Cough with phlegm Coughing up blood Shortness of breath at rest Shortness of breath with activity Wheezing Chest Tightness SLEEP Morning Headaches Excessive Daytime Sleepiness Excessive Snoring Restless Sleep Sleep Disturbance Secondary to Breathing CPAP/BiPAP use GASTROINTESTINAL Heartburn/Reflux Difficulty/Painful Swallowing Abdominal Pain Blood in Stool or Vomit Nausea/Vomiting Colostomy/Ileostomy Hepatitis or Jaundice GENITOURINARY Painful Urination Frequent Urination Blood in Urine Incontinence/loss of bowel or bladder function Frequent bladder/kidney infections Enlarged Prostate GYNECOLOGICAL Are you presently or could you be pregnant? Y N Abnormal Mammogram Abnormal Pap smear Hysterectomy Present or past history of cancer: Breast Y N Please describe: Ovarian Y N Please describe: Uterine Y N Please describe: MUSCULOSKELETAL: Last DEXA: Osteoarthritis Osteopenia/Osteoperosis Rheumatoid Arthritis Fibromyalgia Gout Disc Problems Back Pain Trouble Walking Frequent Falls Pain in Legs with Walking Joint Pain (other than arthritis) Bone Pain NEUROLOGICAL Fainting Spells Balance Problems Tremors Dizziness Seizures Mini strokes/tia Stroke Headaches/Migraines Muscle Weakness Memory Problems Difficulty Swallowing History of Polio BLOOD DISORDERS Anemia Impaired Immune System Low Platelets Unusual Bleeding Blood Clots (in legs or lungs) ENDOCRINE Thyroid Problems Goiter Graves Disease Diabetes MENTAL/EMOTIONAL Excessive Stress Anxiety Depression Suicidal Thoughts Sleeping Difficulty Phobias (i.e. claustrophobia) NPP025 Page 13 Front Piedmont Graphics Rev. 06/29/15
6 North Point Pulmonary Associates 3400 Old Milton Parkway Building C Suite 425 Alpharetta, GA Phone: Fax: MEDICATIONS SUMMARY Please list ALL current medications below: Allergies: Medication Strength Dosage Pharmacy Information: Pharmacy Name Pharmacy Address Pharmacy Phone Number NPP023 Piedmont Graphics Rev. 11/20/15
Please help us provide the best medical care by bringing the following items:
3400-C Old Milton Parkway 1400 Northside Forsyth Drive Suite 425 Suite 240 Alpharetta, GA 30005 Cumming, GA 30041 Phone: 770-343-8760 Fax: 770-664-2101 Phone: 770-292-3120 Fax: 770-292-3121 Welcome to
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**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
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
This form is long! Please feel free to have the doctor or medical staff help you to complete it if you need any assistance at all.
Welcome! This form helps us to meet your medical needs and to provide the best service to you. If you have any questions or need assistance, please ask us. GENERAL PATIENT INFORMATION Name: Home Phone:
Medical History Form
Medical History Form Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best
Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
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
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