48. Any other family history we should know about? Yes No If so, please comment: Number of miscarriages Number of abortions Number of preemies
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1 48. Any other family history we should know about? Yes No If so, please comment: 49. What is the attitude of those close to you about your illness? Supportive Non-supportive FOR WOMEN ONLY (questions 50-58): 50. Have you ever been pregnant? (If no, skip to question 53.) Yes No Number of miscarriages Number of abortions Number of preemies Number of term births Birth weight of largest baby Smallest baby Did you develop toxemia (high blood pressure)? Have you had other problems with pregnancy? Yes No Yes No If so, please comment: 51. Age at first period Date of last Pap Smear Date of last Mammogram Pap Smear: Normal Abnormal Mammogram: Normal Abnormal 52. Have you ever used birth control pills? Yes No If yes, when 53. Are you taking the pill now? Yes No 54. Did taking the pill agree with you? Yes No Not applicable 55. Do you currently use contraception? Yes No If yes, what type of contraception do you use? 56. Are you in menopause? No Yes If yes, age at last period Do you take: Estrogen? Ogen? Estrace? Premarin? Other (specify) Progesterone? Provera? Other (specify) 57. How long have you been on hormone replacement therapy (if applicable)? 58. In the second half of your cycle, do you have symptoms of breast tenderness, water retention, or irritability (PMS)? Yes No Not applicable
2 59. Please check if these symptoms occur presently or have occurred in the past 6 months. Cold hands & feet Cold intolerance Daytime sleepiness Difficulty falling asleep Early waking Fatigue Fever Flushing Heat intolerance Night waking Nightmares No dream recall MUSCULOSKELETAL: Mild Back muscle spasm Calf cramps Chest tightness Foot cramps Joint deformity Joint pain Joint redness Joint stiffness Muscle pain Muscle spasms Muscle stiffness Muscle twitches: Around eyes Arms or legs Muscle weakness GENERAL: Mild HEAD, EYES & EARS: Conjunctivitis Distorted sense of smell Distorted taste Ear fullness Neck muscle spasm Tendonitis Tension headache TMJ problems MOOD/NERVES: Ear noises Ear pain Ear ringing/buzzing Eye crusting Eye pain Headache Hearing loss Hearing problems Lid margin redness Migraine Sensitivity to loud noises Vision problems Agoraphobia Anxiety Auditory hallucinations Black-out Depression Difficulty: Concentrating With balance With thinking With judgment With speech With memory Dizziness (spinning) Fainting Fearfulness Irritability Light-headedness
3 MOOD/NERVES, Cont d: Numbness Other Phobias Panic attacks Paranoia Seizures Suicidal thoughts Tingling Tremor/trembling Visual hallucinations Mild DIGESTION, Cont d: Mild Fissures Foods "repeat" (reflux) Heartburn Hemorrhoids Intolerance to: Lactose All milk products Intolerance to: Gluten (wheat) Corn Eggs EATING: Fatty foods Yeast Binge eating Bulimia Can't gain weight Can't lose weight Carbohydrate craving Carbohydrate intolerance Poor appetite Salt craving Liver disease/jaundice (yellow eyes or skin) Lower abdominal pain Mucus in stools Nausea Periodontal disease Sore tongue Strong stool odor Undigested food in stools DIGESTION: Upper abdominal pain Vomiting Anal spasms Bad teeth SKIN PROBLEMS: Bleeding gums Acne on back Bloating of: Lower abdomen Whole abdomen Blood in stools Burping Canker sores Cold sores Constipation Cracking at corner of lips Dentures w/poor chewing Acne on chest Acne on face Acne on shoulders Athlete s foot Bumps on back of upper arms Cellulite Dark circles under eyes Ears get red Easy bruising Diarrhea Difficulty swallowing Dry mouth Farting
4 SKIN PROBLEMS, Cont d: Eczema Herpes - genital Hives Jock itch Lackluster skin Moles w color/size change Oily skin Pale skin Patchy dullness Psoriasis Rash Red face Sensitive to bites Sensitive to poison ivy/oak Shingles Skin cancer Skin darkening Strong body odor Thick calluses Vitiligo SKIN, ITCHING: Anus Arms Ear canals Eyes Feet Hands Legs Nipples Nose Penis Roof of mouth Scalp Skin in general Throat Mild SKIN, DRYNESS OF: Mild Eyes Feet Any cracking? Any peeling? Hair And unmanageable? Hands Any cracking? Any peeling? Mouth/throat Scalp Any dandruff? Skin in general LYMPH NODES: Enlarged/neck Tender/neck Other enlarged/tender lymph nodes NAILS: Bitten Brittle Curve up Frayed Fungus - fingers Fungus - toes Pitting Ragged cuticles Ridges Soft Thickening of: Finger nails Toenails White spots/lines
5 RESPIRATORY: Mild URINARY: Mild Bad breath Bad odor in nose Cough - dry Cough - productive Hay fever : Spring Summer Fall Change of season Hoarseness Nasal stuffiness Nose bleeds Post nasal drip Sinus fullness Sinus infection Snoring Sore throat Wheezing Winter stuffiness CARDIOVASCULAR: Bed wetting Hesitancy Infection Kidney disease Kidney stone Leaking/incontinence Pain/burning Prostate enlargement Prostate infection Urgency MALE REPRODUCTIVE: Discharge from penis Ejaculation problem Genital pain Impotence Infection Lumps in testicles Poor libido (sex drive) Angina/chest pain Breathlessness Heart attack Heart murmur High blood pressure Irregular pulse Mitral valve prolapse Palpitations Phlebitis Swollen ankles/feet Varicose veins FEMALE REPRODUCTIVE: Breast cysts Breast lumps Breast tenderness Ovarian cyst Poor libido (sex drive) Endometriosis Fibroids Infertility Vaginal discharge Vaginal odor Vaginal itch Vaginal pain
6 FEMALE REPRODUCTIVE, Cont d: Premenstrual: Bloating Breast tenderness Carbohydrate craving Chocolate craving Constipation Decreased sleep Diarrhea Fatigue Increased sleep Irritability Menstrual: Cramps Heavy periods Irregular periods No periods Scanty periods Spotting between Mild
Number of miscarriages Number of abortions Number of preemies. Number of term births Birth weight of largest baby Smallest baby
48. Any other family history we should know about? Yes No If so, please comment: 49. What is the attitude of those close to you about your illness? Supportive Non-supportive FOR WOMEN ONLY (questions 50-58):
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Patient History Questionnaire Date: Referred By: Name: DOB: Age: SSN: Home Telephone: Cell Phone: E-mail: Blood Pressure: Weight: Height: (Circle) R or L Handed (Check) Medication List Attached Emergency
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.)
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.) TODAY'S DATE Your age DATE OF BIRTH YOUR NAME (Last) (First) (M.I.) REFERRED HERE BY YOUR PAST MEDICAL HISTORY (If YOU have
Balanced Healing Acupuncture, LLC
Balanced Healing Acupuncture, LLC Intake Form NAME: Last First: GENDER: Date of Birth / / Age Email Address Address City State Zip Code Preferred Phone Number Cell Home Work Preferred Method of Communication:
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant