Patient Name Age Date of Birth / / Occupation Do you use your voice as part of your professional duties? Do you use your voice as a performer?
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1 PERSONAL INFORMATION The Johns Hopkins Voice Center Johns Hopkins Outpatient Center New Voice Patient Intake Form Visit Date / / PROFESSIONAL INFORMATION Occupation Do you use your voice as part of your professional duties? Do you use your voice as a performer? No Yes If yes, how? No Yes If yes, how? If you are a singer, please fill out the following section. If you are not a singer, skip to the next section: What is your voice type? What is your style? Classical Pop/Rock What is your level of training (years of lessons, etc.)? Musical Theater Church/Gospel Other What are your aspirations as a singer? How many hours each day/week do you spend: in rehearsal? in performance? VOICE PROBLEM(S) Please summarize your voice problem as briefly as possible What are your voice complaints (What about it has changed? What won t it do that it should, or what does it do that it shouldn t?) How long have you had the problem? Did it start: gradually or suddenly? Was anything else going on in your life at the time of onset? (like cold/flu, yelling, stress, etc?) What makes it better? Worse? Characteristics of your voice problem Check those that apply to you: Voice is raspy Voice requires more effort Voice feels strained Cannot get loud Uncomfortable to use voice Worse in AM Worse in PM Loss of high range Loss of low range Decreased vocal endurance How talkative are you, on a scale of 1 to 7? Check your answer based on your personality, not what your job requires of you: Quiet Listener Average Very talkative Previous diagnosis and treatments? ADDITIONAL INFORMATION Other symptoms Check all that apply: Trouble swallowing Pain with swallowing Throat clearing Coughing/choking while eating Coughing Heartburn Dry/scratchy throat Feeling something stuck in throat Have you ever been told that you have acid reflux or hiatal hernia? Yes No Do you take an antacid medication? Yes No If yes, drug and dose Caffeine How many cups of each do you have each day? coffee tea soda Water How many cups of water do you have each day? Do you feel this is enough? Yes No How often do you eat/drink tomato and citrus foods? Rarely Sometimes Frequently NPQ IN 701A NL (rev 05/10)
2 PERSONAL INFORMATION The Johns Hopkins Voice Center Johns Hopkins Outpatient Center New Patient Form Visit Date / / PHYSICIANS Referring Physician Address City State ZIP Code ( ) ( ) Doctor s Phone Number Doctor s Fax Number Primary Physician Address City State ZIP Code ( ) ( ) Doctor s Phone Number Doctor s Fax Number HEALTH PROBLEM PROMPTING TODAY S VISIT PERSONAL MEDICAL HISTORY Please list PAST and CURRENT medical problems. SURGICAL HISTORY Please list surgeries you have had and the approximate year. Type of Surgery Year Type of Surgery Year FAMILY MEDICAL HISTORY Please list significant medical conditions affecting family members. NPQ 801A NL (rev 05/10) Please continue on reverse side
3 EMPLOYMENT AND SOCIAL HISTORY Occupation Do you smoke? Yes No If yes, packs per day? Number of years? Would you like to quit? No Yes If no, did you smoke in the past? No Yes If yes: packs per day number of years Do you drink alcohol? Yes No If yes, how many drinks do you have in an average week? If no, did you drink in the past? No Yes If yes, when did you stop? Do you take drugs? Yes No If yes, what and how often? How much caffeine do you have each day (soda, tea, coffee, etc.)? Marital Status: Single Married Divorced Separated Widow/er REVIEW OF SYSTEMS Please check any symptoms you currently experience. Constitutional fever chills weight loss fatigue Eyes blurred vision double vision contacts/glasses pain Ears hearing loss ear pain drainage ringing Nose/Sinuses drainage congestion post-nasal drip smell Respiratory cough wheezing shortness of breath Cardiovascular chest pain palpitations leg swelling Gastrointestinal heartburn constipation vomiting nausea Genitourinary frequent urination painful urination incontinence Musculoskeletal muscle/joint pain stiffness back pain Integumentary (skin) rashes dry skin change in hair itching Neurological dizziness fainting weakness tremor Psychiatric depression anxiety memory loss stress Endocrine excessive sweating excessive thirst feel too hot or too cold Hematologic easy bruising easy bleeding history of transfusion Allergic/Immunologic sneezing clear, runny nose frequent colds/flus Do you generally feel anxious or depressed? No Yes If yes, explain Have you even been treated for anxiety or depression? No Yes If yes, explain IF YOU ARE A NEW VOICE PATIENT, PLEASE COMPLETE THE VOICE INTAKE FORM. OFFICE USE ONLY Vital signs: BP / Pulse Resp Temp Wt Ht Pain rating: Physician review Date / / NPQ 801B NL (rev 05/10) Hand Washing is Important to Stop the Spread of Illness and Infection Wash Your Hands After: (and before!) Handling food or eating. Using the bathroom or changing diapers. Sneezing, coughing or blowing your nose. Touching a cut, open sore or wound. Playing outside. Playing with pets or cleaning up after them.
4 Center for Laryngeal & Voice Disorders Lee M. Akst, M.D., Director Heather Starmer, M.A., CCC-SLP Sharon Pickett, RN Amy M. Tirabassi, Medical Office Coordinator (office) (fax) ( ) MEDICATION LIST It is important that you fill this out COMPLETELY. If need be, find out from your doctors, the exact dose of any medicines you are taking. This list should include prescription medicines, over-the-counter medicines, vitamins, and supplements from any source. For example, the list should include aspirin, the contraceptive birth control pill, vitamins, minerals, herbal remedies, sports supplements, and any supplements (powders, tablets, drinks, etc.) from an alternative medicine source or health shop. Name of Local Pharmacy Name of Mail Order Pharmacy City City ( ) ( ) ( ) ( ) Phone Fax Phone Fax Medication Name Dose (How Much) Frequency (How Often) DRUG ALLERGIES (Please list any medicines you have had a reaction to) Name of Medicine Reaction Name of Medicine Reaction Name of Medicine Reaction Otolaryngology- Head & Neck Surgery 601 North Caroline Street 6 th Floor Baltimore, Maryland 21287
5 AUDIO-VISUAL CONSENT FORM JOHNS HOPKINS OUTPATIENT CENTER DEPARTMENT OF OTOLARYNGOLOGY HEAD AND NECK SURGERY During your initial evaluation and any follow-up appointments, your doctor or a colleague may perform a transnasal fiberoptic examination (to visualize your voice box, throat or esophagus with a camera attached to a scope) or take photographs to document your progress. We ask your permission to use the photograph and/or videotape of you and/or your throat as deemed appropriate for research or educational purposes and in addition we may require the use of your medical data. Such material may identify you individually. I give permission: I do not give permission: for the Department of Otolaryngology Head and Neck Surgery to use my audio-visual material and medical data. TELEPHONE CONTACT CONSENT FORM Often patients find reassurance in speaking with others that share the same disorder. We would like permission to add your name and telephone number to our list of patients who are willing to share information and personal experiences with other patients, particularly information about diagnostic and surgical procedures. Your name and telephone number will only be given specifically to patients with similar problems. I give permission: I do not give permission: for the Department of Otolaryngology Head and Neck Surgery to offer my name and telephone number to other patients. X Patient s Signature Date / / X Witness s Signature Date / / NPQ 801C NL (rev 05/10)
6 Johns Hopkins Voice Center Patient Quality-of-Life Surveys Medical Record Number Thank you for completing the following surveys. Answering these questions will help us to learn more about your concerns, so that we can take better care of you. Though it may seem as if the various sections overlap slightly, it is important that we collect the information in this format so that we have interpretable results. The surveys were chosen to be as brief but as thorough as possible. Please don t think too hard about any one question. Filling out all the surveys should take no more than minutes, and often your initial response is better than a response that you have to think about for a long time. Thank you for helping us to take excellent care of you. PERSONAL INFORMATION Visit Date / / First Visit Follow-up Visit Please answer all questions based upon what your voice has been like over the past two weeks. There are no right or wrong answers. Considering both how severe the problem is when you get it, and how frequently it happens, please rate each item below on how bad it is. SURVEYS How much of a problem is this? Check the appropriate response. NOT A A AS BAD A SMALL MEDIUM A LOT AS IT Because of my voice, PROBLEM AMOUNT AMOUNT CAN BE 1. I have trouble speaking loudly or being heard in noisy situation I run out of air and need to take frequent breaths when talking I sometimes do not know what will come out when I begin speaking I am sometimes anxious or frustrated (because of my voice) I sometimes get depressed (because of my voice) I have trouble using the telephone (because of my voice) I have trouble doing my job or practicing my profession (because of my voice) I avoid going out socially (because of my voice) I have to repeat myself to be understood I have become less outgoing (because of my voice) V-RQOL TOTAL QUAL 901A NL (rev 08/10) Please continue on reverse side
7 PERSONAL INFORMATION Visit Date / / SURVEYS Continued Check the appropriate response. Within the last MONTH, how did the following problems affect you? (0=NO PROBLEM 5=SEVERE PROBLEM) 1. Hoarseness or a problem with your voice Clearing your throat Excess throat mucous or postnasal drip Difficulty swallowing food, liquids, or pills Coughing after you ate or after lying down Breathing difficulties or choking episodes Troublesome or annoying cough Sensations of something sticking in your throat/lump in your throat Heartburn, chest pain, indigestion, or stomach acid coming up RSI TOTAL Check the appropriate response. To what extent are the following scenarios problematic for you? (0=NO PROBLEM 4=SEVERE PROBLEM) 1. My swallowing problem has caused me to lose weight My swallowing problem interferes with my ability to go out for meals Swallowing liquids takes extra effort Swallowing solids takes extra effort Swallowing pills takes extra effort Swallowing is painful The pleasure of eating is affected by my swallowing When I swallow food sticks in my throat I cough when I eat Swallowing is stressful EAT-10 TOTAL QUAL 901B NL (rev 08/10)
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Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
INITIAL PATIENT FORM
Patient : INITIAL PATIENT FORM Reason for your visit: Visit Date: Left CIRCLE AREA(S) OF CONCERN: Right TOP/BOTTOM OUTSIDE INSIDE Type of pain: Sharp Burning Soreness Tightness Stabbing Numbness Aching
NEW PATIENT INTAKE FORM
NEW PATIENT INTAKE FORM NAME: DOB: SEX: MALE FEMALE ADDRESS: ZIP CODE: PHONE #: - - WORK#: - - PHARMACY: PHARMACY #: - - WOULD YOU BE INTERESTED IN HAVING ACCESS TO YOUR MEDICAL RECORDS ONLINE? YES / NO
A. Please include any medications (herbal, prescription, or Over-the-counter) and any supplements that you are currently taking.
New Patient Questionnaire Please complete this and bring it with you to your visit. If you have it completed five days or more prior to your visit, please mail or fax it to our office. Most recent treating
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE Date Name (Last, First, M.I.) Address City State Zip Code Phone ( ) Work ( ) Cell ( ) Date of Birth Age Marital Status SSN Employer Employer
Placer Private Physicians: Patient Health Questionnaire [2]
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Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
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History Form for Exceptional Home-Based Care
Patient 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 care possible
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
New Sleep Patient Questionnaire. Name Age Date. General Medical History 1. Please list any surgeries you have had and their approximate dates:
1 John S. Kim, M.D., Diplomate ABSM Lawrence A. Lynn, D.O., FCCP 1251Dublin Rd. Columbus, Ohio 43215 (614) 297-7704 (614) 297-7705 New Sleep Patient Questionnaire Name _ Age Date General Medical History
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
Sleep History Questionnaire
Sleep History Questionnaire Name: DOB: Phone: Date of Consultation: Consultation is requested by: Primary care provider: _ Preferred pharmacy: Chief complaint: Please tell us why you are here: How long
UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
MEDICAL QUESTIONNAIRE (male)
MEDICAL QUESTIONNAIRE (male) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501/502 Fax: 01 2780248 The appointment comprises of a discussion about this questionnaire and a subsequent
Spine New Patient Questionnaire Rev
Spine New Patient Questionnaire Rev 10.13.10 Name: Male Female Temp: Height: Weight: Date of Visit: Date of Birth: Age Today: *Please note this is a multi-part questionnaire. When you are done, please
Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
MEDICAL QUESTIONNAIRE (female)
MEDICAL QUESTIONNAIRE (female) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501 The appointment comprises of a discussion about this questionnaire and a subsequent medical examination.