Health History Questionnaire
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- Emma Woods
- 5 years ago
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1 Health History Questionnaire Page 1 of 8 Thank you for choosing Martin s Point to be your partner in health. To help us give you the highest-quality care, please answer the questions on this form as well as you can. Please bring the completed form with you to your appointment. Your provider may ask some follow-up questions when entering this information into your medical record. If you are unsure of an answer, please write in a question mark (? ). If the question does not apply to you, please write in N/A. You may also add more information in the margins, if needed. Thank you! Last name: Middle: First name: Preferred name: Gender: Date of birth: / / Social Security number: Address: Street: City: State: Zip Code: Phone numbers: Home: Mobile: Work: address: How do you prefer we contact you? Home phone Work phone Mobile phone Mail Usual provider: Language: Race: (Examples: White, Black or African American, Asian, etc.) Ethnicity: (Examples: French, Italian, Mexican, Puerto Rican, Chinese, etc.) Refused Marital status: Married Single Divorced Separated Widowed How did you hear about us? Advertising Word of mouth Primary care physician Patient in practice Specialist physician Hospital Insurance company Other (specify):
2 Page 2 of 8 Are you currently taking any prescribed or over-the-counter medication(s)? No Yes (If yes, please list your medication information below.) Medication name: Dose (mg): How do you take your medication? Date Started: 1 By mouth Other 2 By mouth Other 3 By mouth Other 4 By mouth Other 5 By mouth Other 6 By mouth Other 7 By mouth Other 8 By mouth Other 9 By mouth Other 10 By mouth Other 11 By mouth Other 12 By mouth Other 13 By mouth Other 14 By mouth Other 15 By mouth Other
3 Page 3 of 8 Do you have any allergies? No Yes (If yes, please list allergy information below.) Allergy: Last time you had a reaction? Date: Symptom(s) experienced: Advanced Directive: No Yes Occupation: Education: Less than Grade 8 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 College, 2-year College, 4-year Post-graduate Do you live alone or with others? Alone With others Number of children: Diet: Regular Vegetarian Vegan Gluten-free Carbohydrate Cardiac Diabetic Specific Exercise level: Low Medium High
4 Page 4 of 8 General stress level: Low Medium High Sporting activities: Hobbies/ activities: Smoking status: Never smoked Former smoker Currently smoke every day Currently smoke some days Current smoker how much? Occasional (Not every day) Moderate (Less than one pack a day) Heavy (More than one pack a day) Tobaccochewing history: None Once a day 2 4 times a day times a day How many years have you used tobacco? Alcohol intake: None Moderate Women: 1 drink a day Men: 2 drinks a day Occasional Women: Less than 1 drink a day Men: Less than 2 drinks a day Heavy All: 5+ drinks on same occasion, at least 5 times in the last month Caffeine intake: None Occasional Less than 1 caffeinated drink a day Moderate Heavy 1 2 caffeinated drinks a day More than 2 caffeinated drinks a day Do you use recreational/illicit drugs? Are you sexually active? No Yes How often do you use protection against sexually-transmitted diseases? (Example: condoms or dams) Always Usually Never
5 Page 5 of 8 Do you perform a breast self-exam monthly? No Yes Do you routinely use a seat belt? No Yes Do you currently have a smoke or carbon monoxide detector in your home? No Yes Do you routinely use sunscreen? No Yes Do you routinely use insect repellent? No Yes Are you legally blind in one or both eyes? No Yes Do you have difficulty hearing or are you deaf in one or both ears? No Yes Are there guns in your home? No Yes Do any of your biological family members have any diseases/conditions? No Yes (If yes, list disease(s)/condition(s) information below.) Check disease (if applicable): Relation to patient: Age of family member when disease began: If disease was terminal, age of family member at time of death: Alcoholism Alzheimer s disease Asthma Stroke COPD Coronary artery disease
6 Page 6 of 8 Check disease (if applicable): Relation to patient: Age of family member when disease began: If disease was terminal, age of family member at time of death: Dementia Diabetes Disorder of endocrine system Glaucoma High cholesterol High blood pressure Kidney disease Melanoma Breast cancer Colon cancer Lung cancer Have you had any previous surgeries? No Yes (If yes, list surgery information below.) Check surgery (if applicable): Ablation (cardiac) Ablation (endometrial) Ablation (venous) Amputation Appendectomy Arthroscopic surgery Back surgery Breast augmentation Coronary angioplasty Coronary angioplasty with stent Cataract surgery
7 Page 7 of 8 Check surgery (if applicable): Cesarean section Gall bladder surgery Circumcision Cleft palate/lip repair Colposcopy Coronary artery bypass (CABG) D & C Ear/myringotomy tube placement Eye surgery Frenulectomy Bariatric surgery Gastric surgery Gastrostomy tube replacement Joint replacement Knee surgery LEEP Labial adhesions surgery Lumpectomy Mastectomy (complete) Mastectomy (partial) Neck surgery Neurosurgery Nissen fundoplication Oophorectomy Orthopaedic surgery Other Pacer/AICD placement Prostate surgery Prostatectomy Pyloric stenosis repair Reconstructive surgery Rhinoplasty Septoplasty Splenectomy Strabismus surgery Thyroid surgery Tonsils/adenoid Tracheostomy Tubal ligation Undescended testicle surgery VP shunt placement Valve replacement Vasectomy Have you had any past medical issues or conditions? No Yes (If yes, list any past medical issue or condition information below.) Check medical issue/condition (if applicable): ADD/ADHD Acne Alcohol/drug abuse Allergy (hay fever) Anemia Anxiety Arthritis (osteoarthritis) Arthritis (rheumatoid) Asthma Autism Blood clot (leg) Blood clot (lung) Blood transfusion Breast lump (benign) Cancer (breast) Cancer (cervical) Cancer (colon) Cancer (other type)
8 Page 8 of 8 Check medical issue/condition (if applicable): Cancer (ovarian) Cancer (skin) Colon polyp Concussion Constipation Coronary artery disease Depression Diabetes type 1 Diabetes type 2 Diverticulosis Emphysema/COPD Fractures (broken bones) GERD/heartburn Gallbladder disease Glaucoma Gout Gynecological condition (endometriosis) Gynecological condition (fibroids) Gynecological condition (other) Headaches Heart murmur Hepatitis (other) Hepatitis B Hepatitis C High blood pressure High cholesterol Hip fracture Irritable bowel syndrome Kidney disease/failure Kidney stones Liver disease MRSA infection Osteoporosis Pneumonia Prostate enlargement Recurrent ear infections Seizure/epilepsy Skin condition (abnormal moles) Skin condition (eczema) Skin condition (psoriasis) Sleep apnea Stomach ulcer Stool incontinence Stroke Thyroid (hyper) Thyroid (hypo) Thyroid (nodule) Urinary tract infections (UTI) Urinary (frequency) Urinary incontinence
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
Adult Health History for New Patient
Adult Health History for New Patient Name: Birth Date: Today s Date: Preferred Pharmacy (name and location): Your answers on this form will help your health care provider get an accurate history of your
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
Intake and History Form
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Soc. Sec. #: Phone Number (day): Phone Number (day): Email Address: Emergency Contact: # Preferred Language: _ Race: Ethnic Group:
Preferred Pharmacy. Past Medical History
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Phone Number (day): Phone Number (evening): Email Address: Emergency Contact: Preferred Pharmacy Name: Phone Number: City and
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Reason for visit: Previous and/or Maiden Name: Parent/Guardian Name if patient is minor: Birth date: (M/D/Yr) Gender: Male Female SSN (patient): SSN (guardian, if patient is minor):
Patient Interview Form
Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more White Unknown
Patient Health Forms
Patient Health Forms All forms MUST be completed and signed prior to seeing the Provider First: M: Last: Email Address: Home Address: Best Phone Number to Reach You: Last 4 of your social security #: Marital
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
di tric Jacksonville Kids AUTHORIZATION FOR TREATMENT Date: Date of Birth: Patient Name: Date of Birth: Patient Name: Date of Birth: Patient Name:
Jacksonville Kids di tric AUTHORIZATION FOR TREATMENT Date: Patient Name: Patient Name: Patient Name: Patient Name: Patient Name: Patient Name: Date of Birth: Date of Birth: Date of Birth: Date of Birth:
Comprehensive Patient History Form
Comprehensive Patient History Form Date: Name: D.O.B. Past Medical History: (check all that apply) Acid Reflux Cataracts Heart disease Migraines Alcohol or Drug Problem Colitis/Crohns Heart valve problems
Emergency Contact Name Relationship Phone Primary Care Physician Phone Did a Physician Refer you to us? YES NO Physician Name
TELL US ABOUT YOU (please print) First MI Last Address 1 Address 2 CITY ST ZIP COUNTRY E-mail Opt out of providing E-mail Address Language Preference SSN - - DOB / / Driver s License # ST Phone 1 CELL
NEUROSURGERY PATIENT INTAKE FORM
NEUROSURGERY PATIENT INTAKE FORM Surgical Movement Disorders Center Name: DOB: / / Age: Gender: Male Female (circle one) Height: feet inches Weight: lbs What is the main reason for your visit? Are there
*** ADDRESS: (If address is not provided, you MUST write Patient denied.)
PATIENT INFORMATION NORTHWEST BROWARD ORTHOPAEDICS DATE: ***E-MAIL ADDRESS: (If e-mail address is not provided, you MUST write Patient denied.) Pharmacy Name: Pharmacy Phone Number: Pharmacy Location PATIENT
Welcome to About Women by Women
Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
Mailing Address: Street City Zip
First Middle Last Mailing Address: Primary Phone: Street City Zip Secondary Phone: Date of Birth: Male Female SSN: Emergency Contact Phone: Marital Status: Single Race: American Indian or Alaska Native
DONE! You can now close the browser.
Visit My Doctor Online at kp.org/mydoctor. Prepare for your visit This form will help you prepare for your upcoming visit with your doctor. You can complete it on your computer (Mac or PC) and e-mail it
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
An affiliate of Saint Mary's Health System FRANKLIN MEDICAL GROUP, PC. NEW PATIENT INTAKE FORM. Last Name: First Name: DOB: Age:
FRANKLIN MEDICAL GROUP, PC. NEW PATIENT INTAKE FORM Last Name: First Name: DOB: Age: Date of Service: Present Occupation: Marital Status: Married Divorced Single Widowed Partnered List household Members
Adult Health History for NEW Patients
Adult Health History for NEW Patients Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is
Adult Health History New Patient
Adult Health History New Patient Today s Date PREFERRED NAME DATE OF BIRTH Reason for visit: What are your health goals for the next year? Previous Primary care Provider? Last visit? Specialists (Past
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
o Kidney Cancer o Liver Cancer o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine o Neurological
Adult New Patient Registration PATIENT DOB: / / MONTH DAY YEAR PATIENT NAME: LAST FIRST MI o Abnormal Heartbeat Patient Medical History: Please mark all that apply o Chronic Headaches o Hepatitis C o Neuropathy
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone
Date Patient Last Name First Name Middle Name Gender (circle): Male Female Other: Marital Status (circle): Single Married Divorced Widowed Separated Home Address City State Zip Date of Birth Age Social
Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
Patient Name (First, Middle, Last) Height Weight Date of Birth Social Security # Gender Male Female Ethnicity Race Language Address City State Zip Home Phone Cell Phone Work Phone Other Phone Email Occupation
PATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
PATIENT INFORMATION Name: First Name MI Last Name Date of Birth: / / Sex: Male / Female / Declined SSN: Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Declined Marital Status: Single Married Divorced/Separated
F M S M W D. Age Birth Date Gender Marital Status Cell Phone
MIDWEST DERMATOLOGY CLINIC, PC Patient Legal Name Last First Middle Initial Today s Date Mailing Address Street City and State Zip Home Telephone F M S M W D. Age Birth Date Gender Marital Status Cell
Medication Allergies
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Patient Name: Date of Birth:
Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?
PATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
Evolve180 / Ideal Northwest Health Profile
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FROST FAMILY MEDICINE
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Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency 1 2 3 4 5 6 7 8 9 10 11 12 13
New Patient Paperwork
Name (Last, First, M.I.): M F Email Address: Primary Phone: Race: Today's Date: DOB: Alternate Emergency Phone: Contact: American Indian/Alaska Native Asian African American Caucasian Nat Hawaiian/Pacific
GIDEON G. LEWIS, M.D.
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Adult Health History for NEW Patients
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NAME DATE Page 1. Other. Kidney Removed (Right, Left) Bladder Removed. Ovaries Removed for Endometriosis Breast Biopsy
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Patient History Form
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Primary Care Clinic Adult Patient Demographics
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Patient Interview Form
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Health History for NEW Patients Name: Date of Birth: Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. Please fill in all five
PATIENT HISTORY FORM
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Name: DOB: Sex: Male Female
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Patient Information. First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( )
Today's : Patient Information First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( ) Email: Work Phone: ( ) Primary Care Physican: Cell Phone: (
Cell Phone #: Home Phone #: ** Address (prefer your forever address):
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Patient Information: Date: Last Name: Street Address: City: SS #: First Name: Sex: M F Birthdate: Contact Information:
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This form is long! Please feel free to have the doctor or medical staff help you to complete it if you need any assistance at all.
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Date: PATIENT INFORMATION Name SS# LAST FIRST MIDDLE INITIAL. Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed
Date: PATIENT INFORMATION Name SS# LAST FIRST MIDDLE INITIAL Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed Address Alternate Address STREET CITY STATE ZIP STREET CITY
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:
AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION
Medical Record # Patient Name(s) Date of Birth Social Security # Contact Phone # AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION OBTAIN FROM: (Releasing facility) RELEASE TO: (Receiving entity)
THE OB/GYN CENTRE NEW PATIENT HISTORY
PERSONAL PROFILE NAME: AGE: NAME YOU WOULD LIKE US TO USE: OCCUPATION: MARITAL STATUS: GYNECOLOGICAL HISTORY LAST MENSTRUAL PERIOD (FIRST DAY): AGE PERIOD BEGAN: PRESENT BIRTH CONTROL PAST METHODS OF BIRTH