Room # Critical Care & Pulmonary Consultants, P.C.
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- Mervyn Norman
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1 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 your evaluation and allow you to think about the answers to questions that you will be asked during your visit. Please fully complete this health history and bring it to your appointment. Thank you for your cooperation! Patient Name: Date of Birth: Appointment date: Appointment time: Physician: How were you referred to our pulmonary practice? Reason for Visit Briefly describe the reason for your visit and what you hope to accomplish: Have you had a Pneumovax Vaccine? ( ) Yes ( ) No Have you had a Prevnar 13 Vaccine? ( ) Yes ( ) No Have you had a Flu Vaccine? ( ) Yes ( ) No Past Medical History (Please mark All that apply) Diagnosis Month/Year Onset Diagnosis Month/Year Onset Asthma Bronchitis Emphysema COPD Hay Fever Sinus Disease Pneumonia Interstitial Lung Disease Pulmonary Fibrosis Hives (urticaria) Tuberculosis or + PPD test Atypical Mycobacterial dis. Bronchiectasis Chronic Cough Heart Attack High Blood Pressure Chest Pain Angina Heart Murmur Congenital Heart Disease Abnormal EKG Diabetes Stroke Cancer/type Blood Clots Pulmonary Embolism Deep Vein Thrombosis Bleeding disorder Liver Disease Hepatitis Kidney Disease Sleep Apnea Insomnia Heartburn/GERD Trauma
2 Congestive Heart Failure Have you ever been hospitalized? YES NO If so, for what reason? Admission Date Diagnosis/Problem Length of Stay Comments Family History Alive & Deceased? Well If so, at what age? Cause of Death: Health Problems: Mother Father Please list and surgeries you have had and the approximate date of the surgery. Admission Date Type of Surgery Comments Drug allergies / Adverse Drug Reactions if None please Check Here Name of Medication Reaction Comment Are you allergic to EGGS? Yes No Do Not Know Are you allergic to IODINE? Yes No Do Not Know Are you allergic to CONTRAST DYE? Yes No Do Not Know YES NO DO NOT KNOW Have you ever had skin testing or allergy shots?
3 Medications Please list your current oral and inhaled medications including medication name, dose, and number of times per day you take the medication, and mark whether you take it "regularly" or only "as needed," Please list any "over the counter" medications Medication (Oral and Inhaled) Tablet strength or # puffs # of Times per Day Regular Use Only as needed Comments Do you use oxygen? (If Yes, please mark All that apply) Time of Day Date Started Liters/minute Comments Sleep Activity Continuous Social History Marital Status: Single Divorced Separated Widowed Occupation Any history of toxin or chemical exposure related to current or former occupation or hobbies? Yes No If so, please describe Smoking History Personal Habits Never smoker Do you drink alcohol? Yes No Current or Former smoker If so, what type and how much? Age started Age stopped Ever used illicit drug? Yes No Average # packs per day If so, when and what substance? Current # packs per day Tobacco Products Type Amount
4 List any pets you may have: Have any of your pets died recently? List all of your job experiences from earliest to current List any exposures to what you think might be a toxic substance(s) List any hobbies you may have List any places you may have traveled in the past two years List any time you have spent in the military Exercise activity Do you have an advanced care directive or surrogate care provider? No. If Yes, please describe below. Current or Recent Symptoms: Gastrointestinal: ( ) Indigestion Constitution: ( ) Night sweats or fevers ( ) Diarrhea or constipation ( ) Chills ( ) Choking ( ) Abnormal sweating ( ) Abdominal pain ( ) Weight loss/gain ( ) Difficulty swallowing ( ) Blood in stools Eyes: ( ) Visual difficulty Genitourinary: ( ) Increased urinary frequency at night ENTM: ( ) Nasal congestion or blockage ( ) Difficulty urinating ( ) Nose bleeds ( ) Ear pain/infections Musculoskeletal: ( ) Joint Pain ( ) Mouth sores Skin: ( ) Pain or color change of hands with cold exposure Respiratory: ( ) Shortness of breath ( ) Swelling in legs/feet ( ) Shortness of breath at night ( ) Skin rash ( ) Wheezing ( ) Shortness of breath around animals Neurological: ( ) Tremors ( ) Coughing up blood ( ) New weakness or numbness ( ) Cough ( ) Headaches ( ) Phlegm production ( ) Shortness of breath that is worse at work Endocrine: ( ) Infertility/impotence ( ) Sexual problems Cardiovascular: ( ) Chest pain ( ) Heart palpitations Heme/Lymp ( ) Bruising/Bleeding ( ) Loss of consciousness or passing out ( ) New Swollen Lymph Node ( ) Irregular heart beat ( ) Pain in legs with walking Psychological: ( ) Depression
5 Sleep History Yes No Snore loudly Stop breathing during sleep Choking or gasping during sleep Wake refreshed Wake with headaches Driving accidents or near accidents due to sleeping Tired or fatigued during usual daytime activities Kicking or twitching during sleep Restless, tingling, or crawling feeling in legs Trouble falling asleep (for how long? ) Trouble returning to sleep (for how long? ) Weak feeling in arms or legs when emotional Inability to move (paralysis) on waking 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 in recent times. 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 TV Sitting inactive in a public place (e.g. a theater or a 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 a lunch without alcohol In a car, while stopped for a few minutes in the traffic Chance for Dozing I have reviewed: Date:
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WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
Tallahassee Memorial Sleep Center Patient Questionnaire
Tallahassee Memorial Sleep Center Patient Questionnaire Name _ Age Date Date of Birth Sex Height ft in Weight lbs Neck size inches (If known) Body Mass Index (BMI) (If known) Phone(s) (home) (work) (cell)
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
Height: Weight: Neck Size: Does your work involve shift work? Yes No. Where did you hear about us: Physician Media Friend Other
Personal Information Name: Date of birth: Sex: Male Female Marital Status: Nationality: MRN(for KAUH Patients): Height: Weight: Neck Size: Address: Occupation: Length of work day: Does your work involve
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
Please complete this questionnaire before your appointment.
Date completed: Please complete this questionnaire before your appointment. Name: Occupation: Age: Birth date: Gender: M / F Height: Weight: Weight in High School: Neck Size: in. Ethnicity: Hispanic or
New Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist