OUTPATIENT SUMMARY LIST. Social / Family HX. Additional Information: USE A SECOND SHEET IF NECESSARY DO NOT WRITE ON BACK OF FORM.
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1 Washington Institute of Surgery, LLC M Street, N.W. Suite 501, Washington, DC Tel: (202) Fax: (202) Web: OUTPATIENT SUMMARY LIST MR #: DOB: USE A SECOND SHEET IF NECESSARY DO NOT WRITE ON BACK OF FORM Name: Physician: Start Date ACUTE PROBLEMS Stop Date Date Noted ALLERGIES: Drugs, Foods, Substances (i.e. Latex) Start MEDICATIONS: Prescription / Over-the-Counter / Vitamins /Herbs / Dietary Supplement Stop CHRONIC PROBLEMS Date HOSPITALIZATION / SURGERY Smoking Alcohol Family Hx Social Hx Other Social / Family HX Additional Information:
2 Patient Name PATIENTS, PLEASE FILL IN PAGES 1-3 WITH THE EXCEPTION OF SHADED AREA SEX: Male Female Age Requesting Physician: Primary Physician: Other Specialists: Reason for Visit (Chief Complaint): Duration or Problem: weeks months years unsure Pain Rating on 0-10 Scale: (0=No pain; 10=Worst Pain) Location of Pain: Is Pain: New Chronic BP HR RR Temp/Route HT WT BMI History of Present Illness: PAST MEDICAL HISTORY (Please check all that apply) High Cholesterol Stroke/TIA (mini stroke) Irregular Heart Rhythm Conuregestive Heart Fail Heart Attack Heart Valve Problems/Murmur High Blood Pressure Emphysema /COPD HIV Infection Hepatitis (Type: A B C D E or G ) Renal Insufficiency Cancer (type: ) Blood Clots Bleeding / Clotting Disorders Diabetes Mellitus Stomach Ulcers Scleroderma Kidney Failure/ Dialysis Coronary Artery Disease Sleep Apnea Other, Please list 1 P a g e
3 OB / GYN HISTORY (Women Only ): Please List Number of: Pregnancies Live Births Abortions Miscarriages How old were you with your first pregnancy: Did you breastfeed: Yes No Menarche (age your periods started): Are you Menopausal: Yes No Unsure Hormone and Orals Contraceptive Use (include name of hormone and how many years you used it): Social History: Tobacco Use: # of Years smoking: # of Packs per day: Date you quit: Alcohol Use: # of Drinks per week: Street Drugs: Marital Status: Single Married Divorced Widowed # of Children & Ages: Occupation: Family History(Check all that apply to your immediate ): Heart Disease Diabetes Stroke / Carotid Disease Lung disease Bleeding/Clotting Disorder High Blood Cholesterol Family History Unknown Family History Non- contributory Aneurysms Cancer (list all Types ) 2 P a g e
4 REVIEW OF SYSTEMS (Please check any symptoms you currently experience): GENERAL RESPIRATORY GENITOURINARY Chronic Cough Shortness of Breath Urinary Urgency Loss of Appetite At Rest Urinary Hesitancy Unexplained Weight Loss / With Activity Weak Urine Stream Gain Fever / Chills Daily Cough Urinating at Night Intolerance to Heat / Cold Dry Productive Pain with Urination Frequent Thirst Pain with Deep Breath Burning Swollen Glands Sleep Apnea MENTAL HEALTH Jaundice Home Oxygen Depression Fatigue Snoring Anxiety Excessive Daytime Sleepiness HEMATOLOGIC Recovering Alcoholic / Substance Abuser Irritability Easy Bruising Psychiatric Condition Requiring HEENT (Head, Ears Nose, Clotting Disorder Medications Throat) Blurred Vision GASTROINTESTINAL Hospitalization Change in Vision Nausea / Vomiting BREAST / SKIN Hearing Loss Constipation Skin Condition (describe) Sore Throat Diarrhea Difficulty Swallowing (Solids / Liquids / both) Gas Lump (location) Pain Swallowing Change in Urine Color Hoarseness Change in Stool Color NEUROLOGIC Dental Fillings / Caps Abdominal Pain Dizziness (How many ) Change in Voice Heart Burn Headache Goiter (increased neck girth) Standing Lying Wake-Up Passing Out CARDIOVASCULAR Regurgitation Memory Loss Palpitations Feeling Full Quickly with meals Poor Concentration Chest Pressure / Pain Provokes Symptoms: Swelling in Legs Fatty Food Coffee Chocolate Tea Spice Additional Symptoms: All other systems negative Level 1 Problem Focused (0) Level2 Problem Pertinent (1) Level 3 Extended ( 2 to 9) LEVEL 4 and 5 Complete (10 +) 3 P a g e
5 PHYSICAL EXAM: Constitutional: No Acute Distress WN / WD Other: Eyes: EOMI PERRLA Conjunctiva Pink Sclera: Anicteric icteric Other: Ear, Nose, Throat: Assessment of Hearing: Normal Abnormal: Oropharynx: Normal Abnormal: Other: Neck: Thyroid: Normal (no masses, tenderness, enlargement, or bruit) Abnormal: Trachea Midline Other: Neck Circumference: Lymphatic: Normal ( no Lymphadenopathy of the head, neck clavicular, epitrochlear, axillary, or inguinal regions) Other: Breast: Normal (no masses, nipple discharge, dimpling, or asymmetry) Other: Integument: Normal (no rashes, lesions, nodules, or lumps) Other: Wound / Incision: Respiratory: Normal (clear to auscultation, ease of effort, symmetric expansion) Abnormal: Cardiovascular: Heart Sounds: Normal (RRR, S1S2, no murmur, rug, or gallop) Abnormal: Peripheral Pulses: Normal Abnormal: Edema: No Yes: JVD: No Yes: Varicosities: No Yes: Other: Abdomen: Normal (no masses, tenderness, thrills, or pulsations) Abnormal: Hernia: No Yes: Liver / Spleen: Normal Abnormal: Rectal: Normal Abnormal: Murphy s Sign No Yes ther: Genitourinary: Male: Scrotum / Testes: Normal Abnormal: Prostate: Normal Abnormal: Other: Female: Pelvic Exam: Musculoskeletal: Steady Galt Normal Strength Diagram Of: Neurologic: Alert / Oriented x 3: No Yes CN Grossly Intact No Yes Sensation Intact No Yes Other: Psychiatric: Judgment Intact: No Yes Pleasant / Cooperative Other: LEVEL 1 Problem Focused ( 1 5) LEVEL 2 Expanded Problem Focused (6+) LEVEL 3 Detailed (2 each or 6 or 12 each of 2) LEVEL 4 and 5 Comprehensive (2 each of 9) 4 P a g e
6 REVIEW OF DATA: Assessment (Medical Decision Making): Treatment Plan: Cardiac Clearance Pulmonary Clearance Anesthesia Labs: EKG Chest X-Ray Sleep Apnea Screening Patient is to follow-up 2 weeks after the prescribed tests / consultations are completed. Total Visit Time Minutes Total Time Spent for Counseling and Coordination of Care Minutes Counseling and Coordination of Care Activities: Condition / Diagnoses discussed with patient / Family Explained recommended diagnostic studies Films / Study results reviewed in detail with patient Medication education provided Explained alternatives, benefits and risks of treatment Explained surgical options Discussed Post-Op care Patient / Family questions addressed Patient Educational materials provided Total Visit Time: New patient ( ): 10 / 20 / 30 / 45 / 60 minutes The attending practitioner was present during the key portions of the patient s visit and reviewed all notes. A report will be sent to the requesting practitioner. Student / Resident / NP Signature Attending Physician s Signature 5 P a g e
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New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
PATIENT HEALTH INFORMATION SHEET
. Norman J. Brodsky, M.D. Board Certified Michael D. Gauwitz, M.D. Diplomate, ABR Taghrid A. Altoos, M.D. Radiation Oncology Hiral K. Shah, M.D. PATIENT HEALTH INFORMATION SHEET NAME: DATE OF BIRTH: AGE:
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
M F HOME ADDRESS CITY STATE ZIP CODE MARITAL STATUS SINGLE MARRIED DIVORCED WIDOWED PREFERRED PHONE NUMBER TO BE CONTACTED
PRESENT ILLNESS INFORMATION INSURANCE PATIENT HISTORY AND PHYSICAL APPOINTMENT DATE: NAME-LAST FIRST M.I. DATE OF BIRTH AGE SEX SOCIAL SECURITY NO. M F HOME ADDRESS CITY STATE ZIP CODE MARITAL STATUS SINGLE
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
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
Health Questionnaire
Patient Name Date of Birth Thank you for choosing Southern Cancer Center for your care. To help us best prepare for your appointment, please complete this form and bring it to your appointment. If you
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5
Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact#: Alternate#: Work#: Date of Birth: / / Sex: Male Female SS# (optional): Marital Status : Single Married Divorced
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give