Patient Intake Form for Allegany Ear, Nose, & Throat
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- Lizbeth Lamb
- 5 years ago
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1 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? If so, please list and describe your reaction. n-medication allergies (please describe reaction): Have you been tested for allergies? If so, when and what were the positive findings? Have you received shots for allergies in the past? If so, when and for what? Which pharmacy do you prefer to use?
2 Past Health History: (Circle if diagnosed with particular disease) Cancer of: Bone Breast Lung Prostate Throat se/throat Chronic Sinusitis Nasal allergies Tonsillitis Sleep Apnea TMJ _ Lungs Asthma Bronchitis Emphysema Tuberculosis _ Genitourinary Renal Failure Renal Insufficiency Stress Incontinence _ Brain Alzheimer s Epilepsy Multiple Sclerosis Parkinson s Stroke _ Glandular Disorders Diabetes type I Diabetes type II Thyroid excess Thyroid nodule Low thyroid hormone _ Head/Face/Eyes/Ears Headaches Glaucoma Macular degeneration Frequent ear infections Meniere s Disease Cardiac Congestive Heart Failure Heart disease Previous heart attack High blood pressure Irregular heart beat Mitral valve prolapse Valves or Stents Abdominal Disorders Gallstones Cirrhosis Diverticulitis GERD Hepatitis Bones Gout Rheumatoid Arthritis Osteoporosis Slipped disk in neck Mental Health Alcohol dependency Drug dependency Depression Immunologic Disorders AIDS HIV Lupus
3 Surgical/Hospital History Have you ever had problems with anesthesia? If so, what type of problem? List any past surgeries, with dates: ne (circle if correct) List hospitalizations for non-surgical reasons, with dates: ne (circle if correct) List any previous serious injuries: ne (circle if correct) Are your immunizations up to date? (circle appropriate response) Have you had any recent studies (labs, x-rays, MRI, CT scans etc.)? Please include location and dates: Are you pregnant? (Circle appropriate response)
4 Family History Do you have a family history of any of the following? Please list relation(s). Cancer of the throat - (circle if appropriate) Cancer of the lung - (circle if appropriate) Cancer of the thyroid - (circle if appropriate) Cancer of the breast - (circle if appropriate) Growth or development problems - (circle if appropriate) Heart Disease - (circle if appropriate) High Blood Pressure - (circle if appropriate) Asthma - (circle if appropriate) Cystic Fibrosis - (circle if appropriate) Cirrhosis of the Liver - (circle if appropriate) Colitis - (circle if appropriate) Kidney Disease - (circle if appropriate) Stroke - (circle if appropriate) Diabetes - (circle if appropriate) Thyroid Disease - (circle if appropriate) Anemia - (circle if appropriate) Bleeding/Clotting Disorders - (circle if appropriate)
5 Social History Do you smoke currently? If yes, how many packs/day and for how many years have you been smoking? Have you ever smoked? If yes, how many packs/day and for how long did you smoke? When did you quit? Do you drink alcohol? If so, how many drinks per day or week do you take? Do you abuse drugs? If so, what drugs do you use?
6 Patient Review of Systems (Circle all that apply) Constitutional Eyes Ears/se/Mouth/Throat ne ne ne Change in appetite Blurred vision Spinning sensation Decreased energy Double vision Ear drainage Dizziness Dry eyes Hearing loss Fatigue Itchy eyes Itchy ears Fever Bulging eyes Ringing in ears Chills Loss of vision Nasal congestion Night Sweats Pain in eye Nasal bleeding Weight Loss/Gain Tearing changes Sneezing Sleep problems Watery eyes Dry mouth Temperature intolerance Unintentional weight loss Hoarseness Lump in throat Difficulty swallowing Heart Lungs Abdominal Disorders ne ne ne Blacking out Cough, nonproductive Abdominal pain Chest pain Cough, productive Tarry or bloody stools Heart murmur Wheezing Diarrhea Pounding heart Coughing up blood Heartburn Shortness of breath Shortness of breath Nausea/Vomiting Leg swelling Gastrointestinal bleeding Genitourinary Musculoskeletal Neurologic ne ne ne Unusual menstrual bleed Limited use of a joint Change in smell Flank pain Muscle tenderness Change in taste Kidney disease Neck pain/stiffness Change in vision Urinary frequency Weakness Off balance Urinary Hesitancy Pain in back Poor coordination Dribbling with urination Pain in joints Weakness on one side of body Incontinence Urinating excessive amounts Numbness on one side of body Seizures Tremor Endocrine Hematologic Allergic ne ne ne Excessive fatigue Excessive bleeding Dark circles under eyes Heat intolerance Excessive bruising Hives Cold intolerance Bone pain Recurrent Infection Increase in neck size Masses in armpit Itchy nose Masses in groin Sneezing
7
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TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
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Past Medical History. Chief Complaint: Appointment Date: Page 1
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Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
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PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
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New Patient Information
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
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NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE Date Name (Last, First, M.I.) Address City State Zip Code Phone ( ) Work ( ) Cell ( ) Date of Birth Age Marital Status SSN Employer Employer
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM
PATIENT MEDICAL HISTORY FORM Name: Date: Social Security #: DOB: Height: Weight: Email: Primary Care Physician: Referred by: Pharmacy Name/Location/Phone Number: Dialysis Center and Phone Number (if applicable):
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
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more