*OC4501* OC-4567 NORTHWEST CLINIC FOR VOICE AND SWALLOWING NEW PATIENT INTAKE. Patient Name: Primary Care Provider: Provider Specialty:
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1 OC4501 Oregon Health & Science University *OC4501* Page 1 of 6 Patient Name: Primary Care Provider: Address: Other Provider: Address: Provider Specialty: Preferred Pharmacy: Please briefly describe the nature of your current problem: How long has this troubled you? Days Weeks Months VOCAL HISTORY: If not already described, have you noted problems in these areas? Hoarseness Swallowing difficulty/ discomfort Breathing difficulty Cough If you have problems with your voice, please indicate which of the following troubles you have noted (Check all that apply) Poor vocal quality Inability to yell Loss of high range Fluctuating voice Trouble voicing in noise Loss of low range Weak voice Whisper voice Lowered pitch Effortful voicing Trouble voicing on phone Elevated pitch Pain with talking Pitch breaks Discomfort with voicing Please describe other voice problems:
2 Page 2 of 6 Please respond to the following questions regarding hoarseness and its impact on your daily activities. (If hoarseness is not a problem for you, please indicate this fact on the table.) Question Never Almost Sometimes Almost Always Never Always F1. My voice makes it difficult for people to hear me. F2. People have difficulty understanding me in a noisy room. F3. My family has difficulty hearing me when I call them throughout the house. F4. I use the phone less often than I would like. F5. I tend to avoid groups of people because of my voice. F6. I speak with friends, neighbors, or relatives less often because of my voice. F7. People ask me to repeat myself when speaking face- to- face. F8. My voice difficulties restrict my personal and social life. F9. I feel left out of conversation because of my voice. F10. My voice problem causes me to lose income. P11. I run out of air when I talk. P12.The sound of my voice varies throughout the day. P13. People ask what s wrong with your voice? P14. My voice sounds creaky and dry. P15. I feel as though I have to strain to produce voice. P16. The clarity of my voice is unpredictable. P17. I try to change my voice to sound different. P18. I use a great deal of effort to speak. P19. My voice is worse in the evening. P20. My voice gives out on me in the middle of speaking. E21. I am tense when talking with others because of my voice. E22. People seem irritated with my voice. E23. I find other people don t understand my voice problem. E24. My voice problem upsets me. E25. I am less out-going because of my voice problem. E26. My voice makes me feel handicapped. E27. I feel annoyed when people ask me to repeat myself. E28. I feel embarrassed when people ask me to repeat myself. E29. My voice makes me feel incompetent. E30. I am ashamed of my voice problem.
3 Page 3 of 6 Please check the word that describes how severe your primary problem is today Not a problem Mild Moderate Severe To the best of your ability, please describe the progression of your problem including the treatment efforts that have or have not been successful. (Please include any medical treatment as well as any therapies.) Please list any studies you have had for this or any other recent evaluation of the head or neck. Studies of interest include: CT or MRI scans of the head, neck or chest, swallowing evaluations, laryngeal or stroboscopic examinations, swallowing studies, esophageal or upper GI endoscopies, etc... If at all possible, please obtain copies of the reports or the studies themselves and bring these with you to your visit. This will allow for the most efficient and comprehensive evaluation possible and prevent duplication of studies Study: Month/Year: Location: Study: Month/Year: Location: Study: Month/Year: Location: I have more studies listed on the last page of this form. VOCAL DEMANDS (check all that apply): Conversational speech Are you talkative? Heavy telephone use Wireless telephone use Frequent presentations Coaching Teaching Recreational/church singing Professional singing Acting If you are a singer, Please describe your range: Were you formally trained? Please describe: Please describe your singing style: Please describe the venues or situations in which you sing most commonly: Do you warm-up before singing? If so, please describe your typical warm-up: Are you monitored when you sing? If so, please describe type (floor, in-ear, etc...):
4 Page 4 of 6 MEDICAL HISTORY: Please list all current medical problems. Please include all conditions for which you take prescription or over-the counter medication. I have more medical problems listed on the last page of this form. Please list all surgeries you have had on the head or neck. Please include all childhood procedures, including tonsillectomy, adenoidectomy, etc. I have more head or neck surgeries listed on the last page of this form Please list all other surgeries, procedures or hospitalizations you have had. Please be sure to include any procedures or hospitalizations you have had recently that required general anesthesia. I have more surgeries, procedures or hospitalizations listed on the last page of this form Medications: Please list all of your current medications with strength and dosage: An attached list is also acceptable I have more medications listed on the last page of this form Please list any medications to which you are sensitive or allergic: Reaction: Reaction: Reaction: I have more allergies listed on the last page of this form
5 Page 5 of 6 SOCIAL HISTORY: Please describe your current profession: Employer: Profession: Previous Professions: Please describe your social situation: Are you Married With significant other separated divorced Widowed Single Other Do you have children? If so, Please describe ages Do you have supportive family members in the vicinity of Portland? Yes No Please describe your smoking history: I was never a smoker. Current smoker of packs per day for the past years Former smoker of packs per day for year and quit in (year) I smoke products other than cigarettes, including: Please describe your alcohol use. (1 drink = 12 oz beer, 4 oz wine, or 1oz liquor) Never or rarely drink (less than 1 drink/week) I often drink more than 2 drinks per day and average about I have a personal history of heavy drinking in the past I drink most days (1 drink/day) drinks/day Please describe any other drug, alcohol or tobacco use in the past 5 years: Please describe your current fluid intake. (1 glass or cup in about 8 oz) I drink about I drink about oz of water/non caffeinated fluid daily, usually in the form of oz of caffeinated fluid daily, usually as Have you noted problems in any of these areas? If so, please provide details. Unintentional weight loss of lbs over months Intentional weight loss of lbs over months Weight gain of lbs over months Fevers or night sweats Asthma/emphysema/COPD Coughing of blood
6 Page 6 of 6 Please answer the following questions regarding heartburn or laryngeal reflux: within the past month, how did the following problems affect you? 0 = No problem 5 = Severe problem Hoarseness or a problem with your voice 2. Clearing your throat 3. Excess throat mucous or postnasal drip 4. Difficulty swallowing food, liquid or pills 5. Coughing after you ate or after lying down 6. Breathing difficulties or choking episodes 7. Troublesome or annoying cough 8. Sensations of something sticking in your throat or a lump in your throat 9. Heartburn, chest pain, indigestion or stomach acid coming up History of heart murmur History of heart attack History of arrhythmia or palpitations History of stomach ulcers or bleeding History of liver problems or hepatitis History of kidney problems History of bleeding/clotting disorder History of hand, leg or head tremor History of involuntary facial or eye movements History of stroke History of anxiety or depression History of sleep disorder FAMILY HISTORY: Does anyone in your family have a history of any of the following? Cancer Thyroid disease Tremor Movement disorder Please use the remaining space to add additional information:
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Page 1 of 7 GENERAL INFORMATION Name: Date of Birth: Age: Social Security #: Sex: Height: Weight: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Employer s Name: Marital Status: Married
SPINE PROGRAM NEW PATIENT FORM
Name: Date of Birth: Today s Date: Are you right or left handed? What are your goals for the visit? Who referred you to us? Primary Doctor Another Doctor Dr. Of what specialty? Someone else: PAIN 1. Tell
PATIENT HISTORY: PROFESSIONAL VOICE USERS NAME AGE SEX RACE HEIGHT WEIGHT DATE
PATIENT HISTORY: PROFESSIONAL VOICE USERS NAME AGE SEX RACE HEIGHT WEIGHT DATE 1. How long have you had your present voice problem? Who noticed it? Do you know what caused it? Yes No If so, what? Did it
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
1960 FP CENTER FOR SLEEP DISORDERS
1960 FP CENTER FOR SLEEP DISORDERS Sleep Questionnaire Name: Date: Date of Birth: / / Age: Gender: Height: Weight: lbs. Referring Physician: Occupation: Please give a brief description of your sleep problem
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please