Rex Surgical Specialist (Bariatric Office)
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1 Rex Surgical Specialist (Bariatric Office) Medical History Information Today s Date Name DOB Referring Physician phone_ Primary Care Physician phone_ Office Office Medical History (Please Mark all that apply) Acid Reflux/Heart Burn Anemia Anxiety Arthritis Asthma Bipolar disorder Blood Clots/Bleeding Disorders Cancer (type)_ CHF Chronic Constipation Chronic Diarrhea Cirrhosis COPD Depression Diabetes Diverticulitis Epilepsy Ulcers Fibromyalgia Gallstones/gallbladder disease Gout Heart Disease Heart Attack Hepatitis High Blood Cholesterol HIV/AIDS Hypothyroidism Kidney Disease Lung disease Pancreatitis Pseudotumor Cerebri Reflux Sleep Apnea Stroke Thyroid disease/goiter Please list any other health conditions that were not listed. _
2 Surgical History (Please mark all that apply) Appendectomy Brain Surgery Breast Surgery Colon Surgery C-section Cosmetic Surgery Stent Placement Defibrillator Small Intestine surgery Valve replacement Eye surgery Fracture Repair Gallbladder surgery Open heart Surgery Hernia Surgery Hysterectomy Pacemaker Prostate surgery Spine surgery Vasectomy Joint replacement: Type Previous bariatric surgery Type Other surgeries not listed: Allergies (Please list all allergies and reactions) Pharmacy
3 Name_Address Current Medications (Please list name of medication, Dose, and amount you take daily) _ 5.11._ 6.12._ Family History Relationshi p Alive/ Deceased Birth defect s Breas t cance r Clotting disorde r COPD Heart diseas e Hypertensio n Kidney diseas e Diabetes Mother Father Sister Brother Daughter Son Social History 1. Current Nicotine use:
4 Yes No Type of nicotine: How much per day? 2. Have you previously used nicotine? Yes No Type When did you quit? 3. Current Alcohol Use: Yes No How often?_ How much? Type of alcohol? 4. Current Drug Use: Yes No Type of Drug: How Often? Domestic Abuse 1. Is abuse, violence, or sexual assault a problem for you in any way? Yes No 2. Does your partner/caregiver threaten you in any way? Yes No System Review In the past month, have you had any of the following problems? GENERAL NERVOUS SYSTEM KIDNEY/URINE/BLADDER Recent weight gain; how much Recent weight loss: how much Headaches Dizziness Frequent or painful urination Blood in urine
5 Fatigue Weakness Fever Night sweats Fainting or loss of consciousness Numbness or tingling Memory loss MUSCLE/JOINTS/BONES STOMACH AND INTESTINES EARS Numbness Nausea Ringing in ears Joint pain Heartburn Loss of hearing Muscle weakness Stomach pain SKIN Joint swelling Vomiting Redness Where? Yellow jaundice Rash EYES Increasing constipation Nodules/bumps Pain Persistent diarrhea Hair loss Redness Blood in stools Color changes of hands or feet Loss of vision Black stools BLOOD Double or blurred vision HEART AND LUNGS Anemia Dryness Chest pain Clots THROAT Palpitations KIDNEY/URINE/BLADDER Frequent sore throats Fainting Frequent or painful urination Hoarseness Swollen legs or feet Blood in urine Difficulty in swallowing Cough Pain in jaw OTHER PROBLEMS:
6 Sleep Behavior Information 1. My main sleep complaint is: I have trouble sleeping at night I am sleepy all day I have unwanted behaviors during sleep I do not have any complaints 2. Sleep habits: On weekdays, I usually go to bed at AM/PM On weekdays, I usually wake up at _AM/PM On weekends, I usually go to bed at AM/PM On weekends, I usually wake up at _AM/PM I take a nap about days a week The number of times I wake up during the night It typically takes me minutes or hours to fall asleep 3. Sleep behaviors: Please mark all that apply I have sometimes fallen asleep at inappropriate times such as driving, eating, or during a conversation. I have had an accident or near accident when driving because I felt sleepy. I have been told that I snore loudly. I sometimes awaken with a choking sensation. I have been told that I stop breathing when I sleep. I have been told that I grind my teeth at night.
7 I sometimes wake up with a headache. I have trouble falling asleep at night. When I wake up during the night, I have trouble going back to sleep. I wake up too early in the morning. Some nights I never get to sleep no matter how hard I try. Pain often keeps me awake or keeps me from falling back to sleep. I have a job that involves shift changes or night work. As an adult I have been noted sleep walking As an adult I have been heard sleep talking My dreams are often very vivid I have fallen out of bed. I have been told that I have seizures. I am unable to sleep in a flat position because I become short of breath I have been told that I act out my dreams. I have injured myself in my sleep. I go to the bathroom frequently during the night. I wet the bed. I have been told that my legs twitch or jerk while I am sleeping. I usually consume caffeinated beverages during the day. How many?type? Sleep Apnea Treatment 1. Are you currently using a dental device for snoring or sleep apnea? Type of device 2. Have you ever worn a dental device for snoring or sleep apnea? Type of device 3. Are you currently using CPAP/bi-level therapy?
8 4. When did you start using CPAP/Bileveltherapy? _ 5. Have you ever been placed on CPAP/Bilevel therapy? 6. Have you ever had surgery for snoring or sleep apnea? Epworth Sleepiness Scale How likely are you to doze or fall asleep in the following situations? Use the following scale to choose the most appropriate number for each situation. 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation Chance of Dozing 1. Sitting and reading 2. Watching TV 3. Sitting inactive in a public place ( e.g. a theater or a meeting 4. As a passenger in a car for an hour without a break 5. Lying down to rest in the afternoon when circumstances permit 6. Sitting and talking to someone 7. Sitting quietly after lunch without alcohol 8. In a car, while stopped for a few minutes in traffic
9 Total score (please add up numbers) Mental Health History Have you ever been diagnosed with any of the following? Alcoholism Date quit Anxiety Bipolar disorder Depression Obsessive compulsive disorder PTSD Schizophrenia Other 1. Have you ever been hospitalized for a psychiatric condition? If so then When? Reason? Where? 2. Are you currently receiving treatment by a psychiatrist for medication management? Name of psychiatrist 3. Are you currently receiving counseling from a psychologist? Name of psychologist?
10 4. Over the last 2 weeks, how often have you been bothered by the following problems? Not at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things. 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep or sleeping too much. 4. Feeling tired or having little energy. 5. Poor appetite or overeating
11 6. Feeling bad about yourself, or that you are a failure, or have let yourself or family down 8. Moving or speaking slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead, or of hurting yourself. Add Columns + _ + _ = Total:_
12 10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult
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Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
General Information. Name Age Date of Birth. Address Apt. # City State Zip. Home Phone Work Phone. Social Security Number Marital Status
Accredited Member Center of The American Academy of Sleep Medicine 400 Riverside Drive, Suite 1500, Bourbonnais, IL 60914 Phone (815) 933-2874 Fax (815) 939-9413 www.riversidemc.net/sleep General Information
MEDICAL HISTORY QUESTIONNAIRE
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TIM MOORING, M.D. PATIENT QUESTIONNAIRE - PLEASE PRINT
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PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
PEDIATRIC HISTORY FORM
Lehigh Valley Health Network Pediatric Sleep Center PEDIATRIC HISTORY FORM Please answer the following questions frankly and accurately by filling in the blank or checking/circling the appropriate answer.
SLEEP SCREENING QUESTIONNAIRE
Patient Information 433 W. University Dr. Rochester, MI 48307 www.rochesteradvanceddentistry.com +1 248 656-2020 SLEEP SCREENING QUESTIONNAIRE Name: DOB: Age: Address: Employer: SS# Home Phone: Work Phone:
DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
Patient Adult Information History
Patient Adult Information History Patient name: Age: Date: What is the main reason for today s evaluation? Infant History Birth delivery: Normal C-section Delayed Epidural Premature: No Yes If yes, how
Denver, CO Welcome Packet
Fax: (303) 957-5414 or 720-542-8699 For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 1210 S Parker Road, Suite 101, Denver,
Dear Patient: You have an appointment scheduled with SIMEDHealth Pulmonology.
Dear Patient: You have an appointment scheduled with SIMEDHealth Pulmonology. You should read through this package and complete all indicated areas. Some paperwork is related to your health history, some
Patient Medical History
Date: The PMA Metabolic and Bariatric Weight Management Center 410 West Linfield-Trappe Road, Suite 100 Limerick, PA 19468 (610) 495-2338 Patient Medical History Name: Date of Birth: Age: Female Male ALLERGIES:
STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit.
PATIENT HEALTH HISTORY FORM DIRECTIONS AND VISIT DAY INSTRUCTIONS Prior to your Appointment: STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit. STEP