Medication Allergies
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- Clara Lewis
- 5 years ago
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1 **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 Drew V. Hall, M.D Lily H. Delatte, MD Medications (Please list all prescribed or over the counter medications) Name of Medication Dose ( mg, ml) # of tablets or capsules # of times per day each dose Example- Drug A 20 mg One tablet Twice a day Medication Allergies Have you had an allergic or adverse reaction to any medication? Yes complete details below No Medication Type of Reaction
2 Your Medical History Check all that apply Hayfever (allergies) Hearing Loss Glaucoma Cataracts Other ear or eye disease Asthma COPD Valley Fever Lung Nodule Other lung disease High blood pressure (hypertension) Heart Attack (myocardial infarction) Congestive Heart Failure Atrial Fibrillation Elevated cholesterol (hypercholesterolemia) Other heart disease Acid reflux (GERD) Crohn s Disease Ulcerative Colitis IBS ( irritable bowel syndrome) Hepatitis (type) Ulcer of stomach or esophagus Chronic constipation Other gastrointestinal illness Osteoarthritis Rheumatoid arthritis Fibromyalgia Lupus Osteoporosis Osteopenia Other rheumatologic disorder Diabetes Mellitus Hypothyroidism ( low thyroid) Hyperthyroidism ( high thyroid) Menopause age ( women only) Polycystic ovarian disorder (women only) Other endocrine disease Kidney disease Kidney stones (nephrolithiasis) Enlarged Prostate (men only) Frequent urinary tract infections Other kidney disease Stroke or TIA Migraine Headaches Seizures Dementia Parkinson s Disease Other neurological disease Skin cancer Eczema Other skin disease Anemia Leukemia Lymphoma Blood clot Other blood disorder Depression Anxiety Eating Disorder Attention Deficit Disorder Bipolar Disease Other psychiatric illness Cancer ( type)
3 Surgical History Appendectomy Removal of gallbladder (cholecystectomy) Colon surgery Breast surgery Prostate surgery Tubal ligation Vasectomy Hysterectomy Removal of ovaries (oophorectomy) Joint replacement-specify Cardiac Bypass Pacemaker Valve replacement Cardiac cath with stent Other (specify) Family History Family Member Living Deceased/Age Medical Problems/Cause of Death Mother Father Total Living Total Deceased Medical Problems/Cause of Death Sister(s) Brother(s) Son(s) Daughters(s) Other illnesses in the family, please specify: Social History Who do you live with? Self Spouse Family Other, please specify Exercise: No Yes, please specify type and frequency Alcohol: No Yes, please specify type and frequency Caffeine: No Yes, please specify type and frequency Do you currently smoke? No Yes, How much do you smoke? How many years have you been smoking? Have you ever smoked? No Yes, How many years did you smoke? What year did you quit? Occupation: Check if retired and previous profession
4 Immunizations Immunization Date Immunization Date Influenza Pneumovax Shingles (Shingrix) Prevnar 13 Shingles(Zostavax) Gardisil Hepatitis B Tetanus Hepatitis A TDAP Screening Male and Female Stool Cards Date Normal Abnormal Colonoscopy Date Normal Abnormal Bone Density Date Normal Abnormal Screening Male PSA Date Normal Abnormal Testicular Exam Date Normal Abnormal Screening Female Pap Smear Date Normal Abnormal Mammogram Date Normal Abnormal
5 Review of Systems Only circle any symptoms you are currently having or have had and are concerned about. General HEENT Heart/Vascular Respiratory Weight loss Weight gain Fever Chills Fatigue Insomnia Visual changes Photophobia Eye itching Eye Redness Loss of hearing Ear infection Nose congestion Nose drainage Nose bleeding Sinus congestion Sore throat Hoarse Voice Chest pain Rapid heart rate Irregular heart rhythm Leg swelling Pain in the legs when walking Shortness of breath Coughing Wheezing Snoring Gastrointestinal Blood Disorder Musculoskeletal Skin Stomach pain Nausea/vomiting Heartburn Trouble swallowing Diarrhea Constipation Blood in stool Stool incontinence Hemorrhoids Bleeding disorder Easy bruising Anemia Lymphatics Enlarged lymph nodes Lymphedema Joint pain Joint swelling Muscle pain Back pain Neck pain Fractures Rash Hives Dry skin Eczema Skin cancer Nervous System Psychiatric Genitourinary Men Dizziness Spinning Numbness/tingling Gait disturbance Balance difficulties Seizures Headaches Depression Anxiety Phobias Eating disorder Substance Abuse Burning with urination Frequent urination Nighttime urination Urinary incontinence Blood in the urine Sexual difficulties Difficulties with urination Weak stream Scrotal/testicular lump STD.s Pre Menopause Post Menopause Breast Irregular menses Painful menses Vaginal discharge STD s LMP Vaginal dryness Hot flashes/night sweats Vaginal Bleeding STD s Breast lumps Nipple Discharge
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
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Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
Medical History Form
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Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
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DATE OF BIRTH: MELANOMA INTAKE
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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
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone: