CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
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1 IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Occupation: Marital Status: Preferred method of contact: Employer: Years of Education/Degree: REASONS FOR EVALUATION Who referred you to this practice? Please state your concerns; specify nature of problem, onset, duration, frequency, and severity: Current or recent stressors: Goal(s) for treatment: Patient and Family Intake Form Page 1
2 MEDICAL/PHYSICAL HISTORY Primary Care Physician: Phone #: Medical problems (active and past): History of medical hospitalizations and/or surgeries: Current list of medications: Yes None Name of medication(s): Condition(s): Prescribing MD: Dose/schedule: Response/side effects: Homeopathic, naturopathic, herbal and/or other alternative medicine treatments for physical health: Yes None Have you had any problems of the following (please give details): 1. Constitutional: weight changes, appetite changes, chills, fever, night sweats, fatigue / tiredness, lethargy, persistent infections 2. Head and Neck: head injury/ headaches/ migraines/ neck stiffness/ pain/ swollen glands 3. Eyes: sudden loss or change in vision / burning or itching; excessive tearing / redness / discharge / swelling of lid or growth/ double vision/ dryness 4. ENT (Ears, nose, mouth and throat): sinus pressure / congestion / post nasal drip/ ear pain/ ear discharge/ hearing loss / ringing/ dizziness/ dry mouth /bleeding gums/ nose bleeds/ hoarseness/ difficulty swallowing Patient and Family Intake Form Page 2
3 5. Cardiovascular: chest pain / shortness of breath / palpitations/ exercise intolerance / ankle swelling/ cyanosis/ fainting/ lightheadedness/ high blood pressure 6. Respiratory: Congestion/ cough dry/ productive/ blood tinged sputum / wheezing / shortness of breath/ snoring 7. Breast: lump/ nipple discharge/ nipple pain/ recent size changes/ swelling or glands/ skin changes 8. Gastrointestinal: nausea / vomiting / indigestion/ diarrhea / constipation/ abdominal pain / bowel pattern changes/ bloody stools / black tarry stools/ appetite changes 9. Genitourinary: Incontinence / Blood in urine / Pain with urination / Difficulty emptying/ increased frequency of urination/ testicular mass/ testicular pain/ menstrual irregularities/ cramps/ hot flushes/ excess bleeding/ missed cycles/ discharge(foul smelling/ non foul smelling)/ sexual dysfunction / contraception use 10. Integumentary: Rash; itching vs non itching / Excessive dryness / nail/ hair/ skin changes or discoloration / Bumps or nodules/ warts or growths changing in size 11. Neurological: Headache / Loss of balance / Weakness / Tingling/ Tremors/ Loss of consciousness/ Seizures/head injury/ memory loss/ inattention/ sensory loss 12. Musculoskeletal: weakness/ pain or swelling of joints / Loss of range of motion/ chronic pain; location Loss of sensation/ joint stiffness/ 13. Hematologic / Lymphatic: Increased frequency of infections / Non-healing wounds / Bruises / Excessive bleeding Excessive clotting 14. Allergic / Immunologic: Allergies to new medicines / foods / clothing / Hay fever 15. Psychiatric: mood changes/ psychotic symptoms/ Changes in sleep. Appetite and energy states/ body image disturbances/ anxiety / panic attacks/ developmental delay/ social and communicative issues/ speech changes or delay/ memory changes/ obsessions and compulsions/ 16. Endocrine: Increased urination or thirst / Palpitations / Anxiety / Fatigue / energy changes/ skin changes/ metabolic change if any in recent labs/ cold or heat intolerance/ sweating excessively 17. Gyn/ Obstetric issues; pregnancy details/ outcomes/ contraception use Any pain issues or concerns? Yes No If yes, explain: Patient and Family Intake Form Page 3
4 FAMILY MEDICAL HISTORY List family history of medical disorders, psychiatric illnesses and treatments (both maternal, paternal and sibling history related to patient): DEVELOPMENTAL HISTORY Comment on gestational/ birth complications, developmental milestones, early childhood behaviors, parental support and peer relationships : PAST PSYCHIATRIC HISTORY Specify with most recent dates. List history of psychiatric hospitalization and/or residential treatment(s) with reason for hospitalization(s): List outpatient psychiatric/psychological/mental health services (current and past services) Provider Name(s): Dates of tx: Services provided: Outcomes: Termination reason(s): Patient and Family Intake Form Page 4
5 List previous trials of psychiatric medications and recent for changes/ treatment cessation: Name of medication(s): Condition(s): Prescribing MD: Dose/schedule: Response/side effects: History of self-harm or suicidal attempt, if any: Yes No What are the means of self-harm or suicidal attempts? Duration of self harm? Last event was? History of abuse/ neglect/ trauma you may have experienced in your life: Yes No Past/ current substance use/abuse? Cigarettes drugs alcohol drugs/alcohol remission 90+ days none If yes, please describe onset of use, substances used, amount/frequency and impact on function: History of legal issues? Yes No (History of arrest, detention, gang involvement, diversion, divorce, custody etc.,) SOCIAL HISTORY Marital status: Current living situation: Current stressors you or your family is experiencing. List family members / friends and / or adults in the area that you can rely on for help? Yes No Patient and Family Intake Form Page 5
6 Interests and strengths that help you cope: ACADEMIC / WORK HISTORY School/ Grade/ Performance or if completed education specify education level/ area of interest: 504 or IEP plans or accommodations in school: Details of Neuropsychological / Cognitive Testing results, if any: Current work status: provide details of work/ achievement(s) / performance (s) and interpersonal relationship issues if any: Is there anything important you would like me to know? Patient and Family Intake Form Page 6
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
SANTA MONICA BREAST CENTER INTAKE FORM
SANTA MONICA BREAST CENTER Who referred you to see us today? Who is your primary care physician? Are there any other MDs who you would like to receive today s visit information? No Yes MD contact info
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
Headache Follow-up Visit Form
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Questionnaire for Lipedema Patients
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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
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
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
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
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
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Medical History Form
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Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:
PATIENT INFORMATION (PLEASE PRINT) SOC SEC #: - - MRN#: Home Phone: Work Phone: Ext: Address: City: Cell Phone: Date of Birth: - - Age: yrs State: Zip Code: Employer: SEX: Male Female Work Address: City:
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PULMONARY MEDICINE PATIENT QUESTIONNAIRE
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PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
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+ Color Change - + Hearing Loss - + Apnea - + Enuresis (urine - + Tremors - + Rash -
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PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
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Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
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PRE-EVALUATION FORM Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol High Blood Pressure Obesity Heart Defect
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Pure Health Natural Medicine
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Premier Internal Medicine of Alpharetta, PC
Patient Information Date / / First Name Middle Initial Last Name Date of Birth / / Social Security # Gender Male Female Marital Status Single Married Separated Divorced Widowed Address Apt # City State
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
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Wynne Huang, M.D. Family Medicine
PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: SS#: - - Address: City, State, Zip Code Single( ) Married( ) Partner( ) Divorced( ) Widowed( ) Legally Separated( ) Male( ) Female(
NEW PATIENT REGISTRATION FORM
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P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
Medical Questionnaire
MEDICIS Health Testing Center Avenue de Tervueren 236 115 Bruxelles Tel : 2/762.5.44 Medical Questionnaire Name :. Maiden name : First name :. Sex :. Address :...... Phone (private) : Office :. Date of
ALLERGIES: EMERGENCY CONTACTS Name Relationship to Patient Home/Cell Name Relationship to Patient Home/Cell
Instructions: Step 1 Call 719-687- 6088 Monday Friday from 12pm to 6pm to schedule your appointment Step 2 Print this PATIENT INTAKE FORM and fill it out Step 3 Scan and email it to us or fax it to us
PRIMARY CARE (719)
PRIMARY CARE (719) 522-1133 Please help us in meeting your health care needs by providing the following information. *Children under 13, please use Pediatric Health History only. Thank you! Patient: Who