PLEASE INDICATE ANY OF THE FOLLOWING YOU ARE NOW EXPERIENCING:
|
|
|
- Wilfred Haynes
- 5 years ago
- Views:
Transcription
1 DATE OF HEALTH HISTORY UPDATE: THIS IS A HEALTH HISTORY UPDATE. PLEASE INDICATE ANYTHING REGARDING YOUR HEALTH (MEDICAL AND DENTAL) THAT HAS CHANGED SINCE YOUR LAST VISIT TO OUR OFFICE. THANK YOU. WHAT IS THE REASON FOR TODAY S VISIT? DO YOU HAVE QUESTIONS OR CONCERNS? HAVE YOUR TEETH EMBARRASSED YOU IN THE LAST YEAR? DO YOU LOVE YOUR SMILE? IS THERE ANYTHING YOU WOULD LIKE TO CHANGE ABOUT YOUR SMILE? HAS YOUR HEALTH CHANGED DURING THE PAST SIX MONTHS? WHO MAY WE THANK FOR YOUR REFERRAL? PLEASE INDICATE ANY OF THE FOLLOWING YOU ARE NOW EXPERIENCING: HEAD/FACE Forehead headaches Temporal headaches Tension headaches Migraine-type headaches Sinus headaches Back of head headaches Scalp tender to touch NECK Lack of mobility Stiffness Neck pain Tired/sore neck muscles Shoulder pain Back pain Arm/finger pain or numbness JAW Jaw pain Jaw joint pain Clicking/popping in jaw joint(s) Grinding sound in jaw joint(s) Pain in cheek muscles Uncontrollable jaw movements Jaw locks open/shut Deviation of jaw to one side EARS Ear pain without infection Decreased hearing Clogged/stuffy feeling in ear(s) Itchy feeling in ear(s) Ringing/buzzing in ear(s) Dizziness Balance problems THROAT Difficulty swallowing Feeling of foreign object in throat Sore throat without infection Voice changes Laryngitis Frequent coughing or clearing EYES Pain in/around eyes Bloodshot eyes Sensitivity to light Tearing of eyes Blurred vision Pressure behind eyes Dark circles under eyes NASAL Sinus pain Sinus problems Post-nasal drainage Allergies MOUTH Abnormal opening Limited opening Bad bite Missing teeth Clenching/grinding teeth Mouth discomfort Inability to find bite Burning tongue Sour or foul taste in mouth SLEEP Snoring Sleep apnea Have been told I snore Have been told I stop breathing Have awoken gasping for air WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING CARE? PLEASE ORDER COMPLAINTS BY NUMBER (1=MOST IMPORTANT, 10=LEAST) THROAT PAIN JAW CLICKING JAW JOINT NOISE JAW LOCKING JAW PAIN NECK PAIN BACK PAIN DIZZINESS EAR PAIN FACIAL PAIN HEADACHES FATIGUE PAIN BEHIND EYES PAIN WHEN CHEWING RINGING IN EARS SHOULDER PAIN LIMITED MOUTH OPENING EAR CONGESTION VISUAL DISTURBANCES SINUS CONGESTION MUSCLE TWITCHING INABILITY TO OPEN MOUTH OTHER: OTHER:
2 HAVE YOU TAKEN FOSAMAX, BONIVA, OR ANY OTHER BISPHOSPHONATE DRUG IN THE PAST Yes No PLEASE LIST OTHER HEALTH PROVIDERS YOU ARE CURRENTLY SEEING. PRACTICIONER SPECIALTY TREATMENT RECEIVED 6. APRX DATE THE EPWORTH SLEEPINESS SCALE The Epworth Sleepiness Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is a simple, self-administered questionnaire that is widely used by sleep professionals in quantifying the level of daytime sleepiness. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life at present and in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing SITUATION Sitting and reading Watching television Sitting, inactive in a public place (e.g. theatre, meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic CHANCE OF DOZING TOTAL SCORE PLEASE INDICATE ANY MEDICATIONS/SUBSTANCES WHICH HAVE CAUSED AN ALLERGIC REACTION ANTIBIOTICS ASPIRIN BARBITURATES CODEINE IODINE LATEX LOCAL ANESTHETIC METALS PENICILLIN PLASTICS SEDATIVES SLEEPING PILLS SULFA DRUGS OTHER OTHER
3 6. PLEASE LIST ALL MEDICATIONS CURRENTLY BEING TAKEN ANTIBIOTICS ANTICOAGULANTS BARBITURATES BLOOD THINNERS CODEINE CORTISONE DIET PILLS HEART MEDICATION INSULIN MUSCLE RELAXANTS NERVE PILLS PAIN MEDICATION SLEEPING PILLS SULFA DRUGS TRANQUILIZERS PLEASE UPDATE THE FOLLOWING MEDICAL/DENTAL HISTORY ADENOIDS REMOVED? TONSILS REMOVED? ANEMIA ARTERIOSCLEROSIS ASTHMA AUTOIMMUNE DISORDER BLEEDING EASILY HIGH BLOOD PRESSURE LOW BLOOD PRESSURE BRUISING EASILY CANCER CHEMOTHERAPY CHRONIC FATIGUE COLD HANDS/FEET CURRENT PREGNANCY DEPRESSION DIABETES DIFFICULTY FOCUSING DIZZINESS EMPHYSEMA EPILEPSY EXCESSIVE THIRST FLUID RETENTION FREQUENT COUGH FREQUENT ILLNESS DETAILS
4 FREQUENT STRESS GENERAL ANESTHESIA GLAUCOMA GOUT HAY FEVER HEARING IMPAIRMENT HEART MURMUR HEART DISORDER HEART PACEMAKER HEART PALPITATIONS HEART VALVE REPL. HEMOPHILIA HEPATITIS HYPOGLYCEMIA IMMUNE DISORDER INJURY TO FACE INJURY TO NECK INJURY TO MOUTH INJURY TO TEETH INSOMNIA INTESTINAL DISORDER JAW JOINT SURGERY KIDNEY PROBLEMS LIVER DISEASE MENIERE S DISEASE MENSTRUAL CRAMPS MULTIPLE SCLEROSIS MUSCLE ACHES MUSCLE TREMORS MUSCLE CRAMPS MUSCULAR DYSTROPHY NEED PILLOW AT NIGHT NERVOUS IRRITABILITY NERVOUSNESS NEURALGIA OSTEOPOROSIS PARKINSON S DISEASE POOR CIRCULATION PRIOR ORTHODONTICS PSYCHIATRIC CARE RADIATION TREATMENT RHEUMATIC FEVER RHEUMATOID ARTHRITIS SCARLET FEVER SHORTNESS OF BREATH SINUS PROBLEMS SKIN DISORDERS
5 SLOW HEALING SORES SPEECH DIFFICULTY STROKE SWOLLEN JOINTS FREQUENT COLDS FREQ SORE THROAT FREQ EAR INFECTION TUBERCULOSIS TUBES IN EARS TUMORS URINARY DISORDERS 3RD MOLAR EXTRACTION FOSAMAX USE I CERTIFY THAT THE ABOVE HISTORY IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. SIGNED NAME: PRINTED NAME: X
SLEEP SCREENING QUESTIONNAIRE
Patient Information 433 W. University Dr. Rochester, MI 48307 www.rochesteradvanceddentistry.com +1 248 656-2020 SLEEP SCREENING QUESTIONNAIRE Name: DOB: Age: Address: Employer: SS# Home Phone: Work Phone:
Medical History Questionnaire
Medical History Questionnaire OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / Allergens No known allergens Iodine Plastic Antibiotics Latex Sedatives Aspirin Local anesthetics Sleeping pills
Patient Health Questionnaire
Patient Health Questionnaire PATIENT Information Date of completion TM Mr. Ms. Miss Mrs. Dr. Name: First Middle Initial Last Age: Date of Birth: Referred by: DDS MD ENT DC Other Location and/or Phone Number
WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT? Please number the complaints with #1 being the most important.
SLEEP SCREEIG QUESTIOAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your
Medical History Questionnaire
Medical History Questionnaire OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / Allergens No known allergens Iodine Plastic Antibiotics Latex Sedatives Aspirin Local anesthetics Sleeping pills
SLEEP SCREENING QUESTIONNAIRE
SLEEP SCREENING QUESTIONNAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your
Patient Health Questionnaire. Last
Patient Health Questionnaire PATIENT INFORMATION Date of completion O MNDX TM OMr. 0Ms. 0Miss 0Mrs. []Dr. First Middle Initial Age: Date of Birth: Referred by: ODDS DMD DENT ODC 00ther Location and/or
Sleep Patient Registration
Sleep Patient Registration Name: Birthdate: Age: City, State, Zip: If patient is a minor, parent or guardian name: Home Ph: Work Phone: Cell: Social Security#: E- Mail: Gender: Female Male Married Single
PREVIOUS ADDRESS: EMPLOYED BY: ADDRESS: SS#: HOME PHONE: WORK PHONE:
SLEEP SCREEIG QUESTIOAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your
What is your chief concern and reason for this visit: What are the results you are seeking from treatment:
Comprehensive Health Questionnaire Patient Information Mr. Ms. Miss Mrs. Dr. First Name: Middle Initial: Last Name: Age: Date of Birth: Height: Weight: Referred by: DDS MD DO DC Other Address and/or Phone
SLEEP SCREENING QUESTIONNAIRE
SLEEP SCREENING QUESTIONNAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your
Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name: Address: City:
ORAL SURGERY/IMPLANT CONSULTATION
ORAL SURGER/IMPLAT COSULTATIO Form 401C This questionnaire was designed to provide important facts regarding the history of your pain or condition The information you provide will assist in reaching a
PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)
PATIENT INFORMATION Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email: Gender: Male ( ) Female ( ) Age: Birthdate: Marital Status: Married ( ) Widowed ( ) Single ( )
Married Single Widowed Legally Separated. Full Time Part-time Retired Not Employed Currently
First Name Last Name MI Preferred Name Gender Birthday SSN M F Same address for entire family Address Address (cont) City State Zip Home Phone Mobile Email Martial status Married Single Widowed Legally
SLEEP SCREENING QUESTIONNAIRE
SLEEP SCREENING QUESTIONNAIRE Please answer each question accurately and to the best of your knowledge, to help us obtain an accurate picture of your health and sleep issues, only this way will we be able
Hi, Sincerely, Nicole R. Patient Treatment Coordinator
Hi, I just wanted to send you this short letter to thank you, and to congratulate you for choosing Dr. Klauer at the TMJ & Sleep Therapy Centre. We so look forward to getting to know you, and we have such
Patient Registration. Patient Information TODAY'S DATE. Chart ID: First Name ID: Other Dentists if applicable. Other Physician Name
Patient Registration ID: Chart ID: First Name Other Dentists if applicable Other Physician Name Last Name TODAY'S DATE Middle Initial Whom may we thank for referring you to our practice? Responsible Party
Patient Adult Information History
Patient Adult Information History Patient name: Age: Date: What is the main reason for today s evaluation? Infant History Birth delivery: Normal C-section Delayed Epidural Premature: No Yes If yes, how
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
A B O U T Y O U D E N T A L I N F O R M A T I O N
1 A B O U T Y O U Full Name: Welcome to Voller Dentistry. We d like to get to know you better so that we can do our best to ensure your total oral health! Marital Status: Spouse s Name: Spouse s Occupation:
Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
New Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
Facial Problem(s) Questionnaire
Facial Problem(s) Questionnaire Full Legal Name: _ Birth Date: Referred by: Referring Dr s Phone#: Referring Dr s Email address: _ Christopher M. Anderson, DMD 1225 Johnson Ferry Road Suite 660 Marietta,
3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication
MEDICAL HISTORY Patient's Name: Birth Date: 1. Has there been any change in your general health within the past year? 2. Are you now under the care of a physician or health care professional? Physician's
What is the chief complaint for which you are seeking treatment in our practice?
Call 1300 7SNORE www.puresleepservices.com.au New Patient Form Please take your time to answer these questions as completely as possible. It will assist us greatly in our effort to provide the best treatment
Patient Name: Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV. Yes No Liver Disease.
Patient Name: Date: HEALTH HISTORY Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV Heart Murmur Tuberculosis ANEMIA Heart Problems Tumor or growth on head/neck Arthritis,
Welcome to the office of
Welcome to the office of Date: 8340 Cleveland Avenue N. Canton, Ohio 44720 330.494.6305 PERSONAL INFORMATION (Please Print Legibly) Last Name: First Name: _ Middle Initial: _ SS #: _ I would prefer to
Welcome to the Koala Center for Sleep Disorders
Welcome to the Koala Center for Sleep Disorders Your health is very important. We are honored to have the opportunity to join you on your wellness journey. In order to provide you with the comprehensive
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading
KODISH DENTAL GROUP. If you could whiten your teeth for a cost anyone could afford, would you do it? Y N
DENTAL History Please check any of the following that apply to you: Sensitvity (Hot, Cold, Sweet) Where? UR LR UL LL Headaches, ear aches, neck or jaw joint pain Mouth Ulcers or cold sores Teeth or fillings
MEDICAL HISTORY FULL NAME D.O.B. SEX
MEDICAL HISTORY FULL NAME D.O.B. SEX MEDICAL PHYSICIAN OF LAST MEDICAL VISIT HOW IS YOUR GENERAL HEALTH? HEIGHT WEIGHT PLEASE CHECK THE BOX TO THE LEFT IF YOU HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV EPILEPSY
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
Medical and Dental Health History Form Getting to Know You As Our Patient
Medical and Dental Health History Form Getting to Know You As Our Patient Account number: Date: Patient name (first and last): Name of previous dentist/location: Date of last dental examination: Date of
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID 83704 (208)884-2922 ***Questionnaire MUST be completed PRIOR to arrival for appointment*** Today s Date / / / / Last First MI DOB Referring
PATIENTS DEMOGRAPHICS
PATIENTS DEMOGRAPHICS Date: First Name MI Last Name Sex: M or F (Circle one) Age: Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell/Pager No: Date of Birth: Single: Married: Social Security
Huron Medical Sleep Center Saad S. Ahmad, MD
Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
New Patient Sleep Intake
New Patient Sleep Intake Name: Date of Birth: Primary Care Physician: Date of Visit: Referring Physician and/or Other Physicians: Retail Pharmacy: Mail Order Pharmacy: Address: Mail Order Phone #: Phone
Room # Critical Care & Pulmonary Consultants, P.C.
Room # Critical Care & Pulmonary Consultants, P.C. Health History You have been scheduled for an appointment with Critical Care and Pulmonary Consultants, P.C. This health history will help us facilitate
PEDIATRIC HISTORY FORM
Lehigh Valley Health Network Pediatric Sleep Center PEDIATRIC HISTORY FORM Please answer the following questions frankly and accurately by filling in the blank or checking/circling the appropriate answer.
PATIENT REGISTRATION INFORMATION DENTAL INSURANCE INFORMATION. Title:! Mr.! Mrs.! Ms.! Miss! Dr. Patient: Last Name: First Name: Middle:
Title:! Mr.! Mrs.! Ms.! Miss! Dr. PATIENT REGISTRATION INFORMATION Patient: Last Name: First Name: Middle: Wish to be called: D.O.B.: / / Age: Sex:!Male! Female SSN: - - Marital Status:! Single!Married!
Sleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118
Sleep Questionnaire *Please complete the following as accurate as possible. Please bring your completed questionnaire, insurance card, photo ID, Pre-Authorization and/or Insurance referral form, and all
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine PATIENT DEMOGRAPHICS Who is the Physician that referred you to us? Who is the primary care Physician? Date: Do you want this report
WELCOME. About You. Dental Insurance. Responsible Party s Information. Emergency Contact. Pharmacy Information
WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we ll be glad to help you. We look forward to working
Sleep Center New Patient Questionnaire
For office use only Appt date: Sleep Center Clinician: Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 #1 respiratory hospital
Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes. Yes No Yes No
Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking,
EMORY SLEEP CENTER Sleep and Health Questionnaire
EMORY SLEEP CENTER Sleep and Health Questionnaire Demographics Today s Date: / / Name: Date of Birth: / / Address: Sex: Male Female City/State/Zip: Preferred Contact Number: Work Home Cell Occupation:
Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4
Morro Bay Family Dentistry 747 Bernardo Ave. Morro Bay, CA 93442 (805) 772-8585 Date: Patient Information Name Birth date SS# Driver's License # Expiration Address City State Zip Home Phone Cell Phone
Littleton, CO Welcome Packet 8151 Southpark Lane, Suite 200 Littleton, CO 80120
Littleton, CO Welcome Packet For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 8151 Southpark Lane, Suite 200, Littleton,
Patient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )
Patient Information Name: Date of Birth: Age: Address: Number & Street City State Zip Code Home Number: ( ) Cell Number: ( ) Social Security Number: Marital Status: Religion: Race: Height: Weight: Sex:
Pre-Test Questionnaire. Name: Sex: Age: Date of Birth: Height: ft. in. Weight: lbs Gain? Loss? of lbs over
Pre-Test Questionnaire Date: Hospital # (Please Print) Name: Sex: Age: Date of Birth: Height: ft. in. Weight: lbs Gain? Loss? of lbs over Chief Complaints What problem(s) brings you to sleep disorders
Sleep Symptoms & History
Sleep Symptoms & History In your own words, please tell us what brings you to the sleep clinic today? How long have you been experiencing your sleep problems? yrs. mos. To give us a precise understanding
130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History
130 Preston Executive Drive Cary, NC 27513 Ph(919)462-8081 Fax(919)462-8082 www.parkwaysleep.com Page 1 of 6 Patient History *Please fill out in dark BLACK INK only. General Information Name Sex: Male
Denver, CO Welcome Packet
Fax: (303) 957-5414 or 720-542-8699 For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 1210 S Parker Road, Suite 101, Denver,
Orofacial pain and temporomandibular joint disorder patient history and questionnaire. Name: Sex: M F Date of Birth: / / Age:
Orofacial pain and temporomandibular joint disorder patient history and questionnaire Date: / / Name: Sex: M F Date of Birth: / / Age: Occupation: Physician: Dentist: Referred by: Chief Complaint/Concern:
SLEEP STUDY - PATIENT QUESTIONNAIRE
NOTE: You cannot fill out this form on Mozilla Firefox, please try another browser. You have two options for completing a questionnaire: - Enter the information on the fillable PDF and click Print at the
PCCSS, LLP Pulmonary, Critical Care & Sleep Specialists
NAME: AGE: DOB: DATE: REQUESTING PHYSICIAN: NOTE: Please help us find out about you by filling out the Patient side of this form on pages 1 3. If you don t know the answer to one of the questions, ask
DESERT CENTER FOR ALLERGY AND CHEST DISEASES HEALTH QUESTIONAIRE NAME. PAST MEDICAL PROBLEMS- Check mark if you have any of the following
DESERT CENTER FOR ALLERGY AND CHEST DISEASES Pulmonary Medicine, Allergy/Immunology, Sleep Disorders Pulmonary Rehabilitation, Pulmonary Function Laboratory HEALTH QUESTIONAIRE NAME What is your presenting
Julia A. Hallisy, D.D.S., Inc.
Julia A. Hallisy, D.D.S., Inc. Welcome! Thank you for choosing our office for your dental health needs. Please let us know if you need assistance when completing these forms. Name PATIENT INFORMATION Last
PEDIATRIC SLEEP EVALUATION
PEDIATRIC SLEEP EVALUATION Directions: Please answer each of the following questions by writing in or choosing the best answer. This will help us know more about your family and your child. CHILD S INFORMATION
Intake Questionnaire
Intake Questionnaire In order to make the best use of your appointment time, please complete this form prior to your initial appointment. What is your name? (Who filled in this form?) (Y= yes N=no DK=
MEDICAL HISTORY. List all medications, supplements, and or vitamins taken within the last two years. Drug Purpose Drug Purpose
DO YOU HAVE or HAVE YOU EVER HAD: 1. hospitalization for illness or injury 2. an allergic or bad reaction to any of the following: aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
Patient Information. Address: Responsible Party/Insurance Policy Holder. (if someone other than patient) First Name: Last Name MI: Address:
Patient Registration (complete form must be filled to process insurance claim) Patient Information First Name: Last Name: MI: Address: City: State: Zip: Home Phone: Cell Phone: Email Address: Would you
Huron Medical Sleep Center Saad S. Ahmad, MD
Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS NPSG CPAP CPAP Retitration Split Night PATIENT INFORMATION: Name: Last First Middle Initial Address: City: State: Zip: Social Security #: DOB: Gender: Age: Phone Number: Cell: Work:
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
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: Pre-fix: Patient s Legal First Name: PATIENT INFORMATION Legal Last Name: Nickname: Mr Mrs Ms Dr Street Address: Home Phone #:
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE. Name: Date of Birth: / / Age: Sex: Address: City: Zip:
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE *Please bring copies of any recent Blood Work and Physician Sleep Referral Order* Please answer every question to the best of your
STEPHEN C. SNITZER, D.D.S.,
STEPHEN C. SNITZER, D.D.S., M.S., P.C. PRACTICE LIMITED TO PERIODONTICS AND IMPLANTOLOGY DATE 14377 WOODLAKE DRIVE, SUITE214 CHESTERFIELD,MISSOURI 63017 (314) 434-2101 NAME How would you prefer to be addressed?
SNORING AND OBSTRUCTIVE SLEEP APNOEA WAYS TO DEAL WITH THESE PROBLEMS
SNORING AND OBSTRUCTIVE SLEEP APNOEA WAYS TO DEAL WITH THESE PROBLEMS Laugh and the world laughs with you; snore and you sleep alone. These words by novelist Anthony Vergess ring true with all too many
Patient Registration
Patient Registration First name: Last name: Patient is: Responsible party Child Address: City: State: Zip: Home phone Cell phone: Work phone: Sex: Male Female Birth date: Material status: Single Married
Kingsland Family Dental Registration and Medical History
Registration and Medical History Date: Patient Information Patient Name: DOB: / / Age Last First M Social Security# - - Sex: M F Marital Status: Single Married Child Other Spouse or Parent Name: Street
Name Home Phone Work Phone Address Cell Phone Occupation Birthdate Employer Spouse Referred by Physician Phone Date of Last Physical Exam
Patient History Form William P. Glaros, DDS Name Home Phone _ Work Phone Address Cell Phone _ Occupation Email Birthdate Employer Spouse Referred by Physician _ Phone Date of Last Physical Exam Past /
Registration. Secondary Dental Insurance Subscriber s Name Date of Birth Social Security # Relationship to Patient Subscriber s Employer
Patient Name of Birth Sex Age How do you wish to be addressed Single Married Separated Divorced Widowed Minor Home Address City State Zip Home Phone # Cell phone # Email Fax # Driver s License # Work Address
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk PATIENT QUESTIONNAIRE
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk 55 Frid Street, Unit 7, Hamilton, Ontario L8P 4M3 Phone:905-529-2259 Fax: 905-529-2262 282 Linwell Road, Suite 118, St. Catharines, Ontario
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY. Patients s Name Date Yes No Yes No
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY Patients s Name Date Yes No Yes No Anemia Arthritis Artificial Joints or Heart Valve Asthma Cancer/tumors Chest
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
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
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:
SUNSET SLEEP LABS PATIENT INFORMATION FORM Patient Information Name: Sex: M F Date of Birth: Address/Street: City: Zip: Phone: Alt Phone: Parent/Guardian: Phone: Social Security Number: Drivers License:
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY
ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY PATIENT INFORMATION Date SS/HIC/Patient ID# Patient Name Responsible Party Address City State Sex M F Age Birthdate Married Widowed Single Minor Separated
PATIENT SLEEP QUESTIONNAIRE
PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb
Sleep History Questionnaire B/P / Pulse: Neck Circum Wgt: Pulse Ox
2700 Campus Drive, Ste 100 2412 E 117 th Street Plymouth, MN 55441 Burnsville, MN 55337 P 763.519.0634 F 763.519.0636 P 952.431.5011 F 952.431.5013 www.whitneysleepcenter.com Sleep History Questionnaire
YOUR NAME AGE DATE. Comments. Describe your sleep problem and how long you ve had it
YOUR NAME AGE DATE Describe your sleep problem and how long you ve had it Have you ever been at a sleep center before? YES NO When? Where? Ever been on CPAP? YES NO WORK SCHEDULE When does your usual work
Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment:
PATIENT INFORMATION (Please Print) Today s Date : Patient s last name: First: Middle: M Jr. Sr. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your
PATIENT INFORMATION DENTAL HEALTH HISTORY
PATIENT INFORMATION Welcome to Pristine Family and Implant Dentistry. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
PATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:
SLEEP DISORDERS INSTITUTE HOSPITAL: DePaul Building Street Address City, State Zip Tel: (202) 555-1212 Fax: (202) 555-1212 SLEEP QUESTIONNAIRE PATIENT NAME: M.R. #: ACCT #: STREET ADDRESS: CITY: STATE:
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
WELCOME Patient Registration Date:
Patient Information WELCOME Patient Registration Date: Mr. Mrs. Ms. Dr. Name: Last First MI Address: Street Apt. # City State Zip Code Home Tel #: Work #: Cell #: Sex: Female Male Birth Date: Married Single
*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.
Fairfax Oral and Maxillofacial Surgery
Fairfax Oral and Maxillofacial Surgery Patient information: Today s Date Mr. Mrs. Ms. Dr. First Name M.I. Last Name Nickname Sex: Male Female Birth Date Age Soc. Sec. # E-mail Street Apt. City State Zip
Dental History. Associates for General Dentistry, Ltd N. Rand Road Arlington Heights, IL (847) AssociatesForGeneralDentistry.
(847)392-4422 afgd 1307@gmail.com Dental History What is the reason for your visit today? Date of Last Dental Visit: Last Dental Cleaning Last set of X-rays What was done at your last dental visit? Q Cleaning
Sleep Medicine Questionnaire
Please bring this completed questionnaire with you to your sleep medicine appointment. Our sleep medicine staff strives to understand your sleep symptoms, which may be complex in nature. Thank you for
PATIENT REGISTRATION
PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
TIM MOORING, M.D. PATIENT QUESTIONNAIRE - PLEASE PRINT
TIM MOORING, M.D. PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Age: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3) Referring Physician Other Physician PAST
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