New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
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1 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 this problem? Yes No If yes, give the name of the physician who did your evaluation or ordered your tests: What tests were performed? 3. Who referred you for this appointment? 4. List any other physicians you see routinely: 5. Have you ever seen a nephrologist? _ Yes _ No If yes, the physician s name: 6. Have you ever: had a kidney biopsy? Dates: had any recent lab tests for kidney function? Dates: had any 24 hour urine collections? had any prior kidney ultrasounds? Dates: _ Dates: _ Past Medical History: Have you had problems with any of the following? If yes, please explain: Cancer.. Diabetes.. High Blood Pressure... Heart Problems.. High Cholesterol Page 1
2 Emphysema or Asthma. Ulcers. Liver Disease. Kidney Problems Protein in Urine.. Kidney Stones.. Cysts/Masses/Cancer in the Kidneys.. Prostate Disease... Thyroid Gland Problems.. Hemorrhages or Bleeding... Anemia.... Arthritis... Convulsions or Seizures... Laser Eye Surgery for Diabetic Eye Disease... Numbness and Tingling Foot Ulcers or Circulatory Disorders.... Erectile Dysfunction... Psychiatric Treatment... Treatment for Depression or Anxiety. Surgeries: Prior Hospitalizations: Month/Year Procedure Month/Year Procedure Current Medications: Medication Strength How Often Taken Medication Strength How Often Taken Page 2
3 Have you ever taken: Advil / Ibuprofen / Motrin / Aleve? If yes, please list: Over-the-Counter Decongestants? If yes, please list: Drug Allergies: Are you allergic to any medications: If yes, please list the medications: Social History: Marital Status: Married Single Separated Divorced Widowed Number of Children: Education: Highest Grade Completed: Highest Degree Completed: Occupation: Work Status: Full Time Part Time Unemployed Retired Student Disabled If you are retired, what was your previous occupation? Habits: How much? How many years? Do you smoke? If no, have you ever smoked? Do you drink alcohol? If no, did you previously drink? IV drug abuse? Had blood transfusions? Have any tattoos? Family History: Living: Present Age/ Present Health or Cause of Death Age at Death Page 3
4 Spouse: Yes No Father: Yes No Mother: Yes No Children: Yes No Number of Brothers: Number of Sisters: Have any of your family members had a condition similar to yours? If yes, please describe: Please answer the following questions: Constitutional Symptoms: Gastrointestinal: Recent Weight Change. Abdominal Pain Fever. Cramps Fatigue. Nausea Sleep Difficulty.. Vomiting Loss of Appetite... Diarrhea Constipation.. Liver Problems. Eyes/Ears/Nose/Mouth/Throat: Jaundice (yellow color in eyes & skin). Eye Problems. Hearing Loss or Ringing in Ears. Chronic Sinus Problems. Musculoskeletal: Nose Bleeds... Joint Pain. Sore Throat or Voice Change. Joint Stiffness or Swelling Swollen Glands in Neck. Weakness of Muscles. Difficulty Chewing or Swallowing.. Muscle Pain or Cramps.. Back Pain.. Cardiovascular: Chest Pain or Angina.. Integumentary (Skin): Irregular Heartbeat or Pounding Heart. Rash or Itching.. Swelling of Feet, Ankles or Hands. Change in Hair or Nails.. Calf Pain When Walking.. Change in Skin Color. Aneurysm History. Change in Color or Size of Moles. Do You Sleep Flat.. Do You Use 2 or 3 Pillows.. Page 4
5 Do You Wake Up from Sleep Short of Breath.. Neurological: Seizures.. Dizziness or Vertigo.. Respiratory: Loss of Consciousness. Chronic or Frequent Coughs. Numbness or Tingling Sensations.. Spitting Up Blood.. Weakness in Limbs Shortness of Breath. Difficulty With Balance.. Asthma or Wheezing... Frequent or Recurring Headaches.. Tremors.. Memory Loss or Confusion. Psychiatric: Genitourinary: Any Psychiatric Disorders.. Frequent Urination. Nervousness Burning or Painful Urination Depression Blood in Urine. Hallucinations. Loss of Control of Urine.. Paranoia or Suspiciousness.. Male Erectile Difficulty.. Kidney Stones. Foamy Urine Endocrine: Decreased Caliber of Stream.. Adrenal Glands and Disorders.. Getting Up at Night to Urinate. Excessive Thirst or Urination. Hesitance or Difficulty in Starting Urine. Heat or Cold Intolerance.. Addison s Disease or Pituitary Disorders. Hematologic/Lymphatic: Bleeding or Bruising Tendency. Inflammation in Leg Veins (Phlebitis).. Cancer. Clots in Leg Veins Anemia.. Transfusions.. Excessive Bleeding. Page 5
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Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)
1275 Olentangy River Rd. Ste 120 Columbus, Ohio 43212 Telephone (614) 291-5555 Fax: (614) 291-7720 Dr. David B. Kaplansky Dr. Randall Contento PATIENT Dr. INFORMATION Garrett Kalmar FORM www.columbusohiopodiatrist.com
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
Broward Oncology Associates, P.A. PATIENT INFORMATION
NAME: BIRTHDATE: AGE: LOCAL ADDRESS (Street city state zip): HOME TELEPHONE# CELL # SOCIAL SECURITY #: - - SEX MARITAL STATUS WHAT IS YOUR HT? WHAT IS YOUR WT? EMPLOYER WORK# SPOUSE'S NAME SPOUSE'S EMPLOYER
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