Welcome to Aguirre Specialty Care (ASC). We are pleased that you have chosen us to evaluate your condition.
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- Anissa Warner
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1 Dear Valued Patient, Welcome to Aguirre Specialty Care (ASC). We are pleased that you have chosen us to evaluate your condition. To facilitate your visit and ensure that ASC will be able to help you, we ask that you complete and return the 3 documents below within 48 hours of making your appointment. These forms are necessary to confirm your appointment. If you do not return these forms within 48 hours, your appointment may need to be rescheduled and or cancelled. You may choose to return the information by fax, mail or secure . Dr. Aguirre will personally review this information to make sure that he has everything necessary to provide a comprehensive consultation on the day of your visit. Patient Information Form New Patient Questionnaire Authorization to Receive Medical Records Please complete the 2 forms below and bring them with you at the time of your appointment. If you have questions or concerns after reviewing our policies please do not hesitate to call our business office to discuss prior to your appointment. There is limited time on the day of your appointment to discuss any concerns regarding our policies. Additionally, our business personnel may not be available at the time of your appointment. If you arrive 15 minutes late or if your forms aren t completed and signed your appointment will be rescheduled. Payment Terms and Agreements Credit Card Consent At your initial appointment, your medical history will be taken followed by a detailed pelvic examination. This will determine the need for diagnostic testing which will be scheduled accordingly. Again, please do not hesitate to call our office with any questions or concerns you may have regarding your appointment. We look forward to meeting you. Sincerely, Dr. Aguirre and Staff
2 Aguirre Specialty Care Oscar A. Aguirre, M.D., Director 9800 Mt. Pyramid Court, Suite #300 Englewood, CO Phone (303) Fax (303) New Patient Questionnaire IMPORTANT: Please complete this questionnaire carefully and return to our office within 48 hours of scheduling your appointment. You may return it by fax, mail or secure to confirm your appointment. Date of Visit: / / Name: Date of Birth: / / Age: CHIEF COMPLAINT Please briefly describe the reason(s) that you are being seen in our office: For how long have you experienced each problem? Please list any previous tests or treatments for each condition: PAST MEDICAL HISTORY Have you ever had any of the following problems? Please circle Yes or No: Explain: Yes / No Bleeding problems (blood clots, anemia, past transfusions) Yes / No Cancer Yes / No Diabetes Yes / No Eye disorder (glaucoma, chronic dryness) Yes / No Neurological problems (seizures, migraines, stroke, fibromyalgia) Yes / No Gastrointestinal disorders (ulcers, reflux,) Yes / No Heart problems (irregular heart beat, murmur) Yes / No Hernia Yes / No High blood pressure Yes / No Kidney problems (stones, infection, decreased function) Yes / No Liver problems Yes / No Musculoskeletal problems (osteoarthritis, loose joints) Yes / No Psychiatric problems (depression, anxiety, bipolar disorder) Yes / No Respiratory problems (asthma, COPD, emphysema, sleep apnea) Yes / No Skin disorder Yes / No Spine injury Yes / No Thyroid disease Yes / No Other:
3 REVIEW OF SYSTEMS Check any conditions present today: I have none of these problems today Constitutional Recent weight change Fever Weakness HEENT Visual problems Hearing problems Dry mouth Cardiovascular Chest pain Varicose veins Blood clots Respiratory Chronic cough Wheezing Oxygen use Gastrointestinal Heartburn Nausea/Vomiting Hemorrhoids Musculoskeletal Muscle pain Joint pain Limited mobility Neurological Paralysis Numbness Tingling Skin Rashes Sores Lumps Endocrine Hot flashes Excessive thirst Hematological Easy bruising Immunologic Swollen lymph nodes Psychiatric Depression Anxiety OBSTETRICAL HISTORY Skip this section. I have never been pregnant. Number of pregnancies: Miscarriages: Abortions: Living Children: Date: Weight: Type of Delivery: 3 rd / 4 th Degree Tears: vaginal vaginal with forceps/vacuum C-section Yes / No GYNECOLOGICAL HISTORY Do you have menstrual periods? Yes No (skip to next question) First day of last period: / / Age at first period Number of days between periods Duration of bleeding: Do you bleed between periods? Yes No Do you have heavy periods? Yes No Do you have a need for birth control? Yes No (skip to next question) What method of birth control are you and your partner using? Would you like to discuss a permanent method of birth control? No Yes Have you gone through natural menopause? No Yes If yes, at what age? Have you had a hysterectomy? No Yes If yes, abdominal vaginal Reason for hysterectomy Were your ovaries removed? No Yes If yes, which ovary(ies)? left right both Date of last pap smear / / Normal? Yes / No Have you ever had an abnormal pap? Yes / No Date of last mammogram / / Normal? Yes / No Have you had a sexually transmitted disease? No Yes If yes, please list:
4 SURGICAL HISTORY Skip this section. I have never had any type of surgery. List ALL surgeries with the date, if possible. Include abdominal and plastic surgeries MEDICATIONS Skip this section. I do not take any medications. List all of the medications that you currently take, including over-the-counter medications and herbal supplements. List the dosage and how often you take it. ALLERGIES Skip this section. I have no known allergies. List any allergies along with the type of reaction you experience. SOCIAL HISTORY Marital status: Single Married Divorced Separated Widowed Living situation: Alone Family Skilled nursing facility/nursing home Other Tobacco use: Yes No Daily amount Number of years Alcohol use: Yes No Daily amount Street drug use: Yes No Type and daily amount Caffeine use: Yes No Type and daily amount Abuse: Yes No Describe Exercise: Yes No Type and how often FAMILY MEDICAL HISTORY Please circle Yes or No: Relationship: Yes / No Bleeding disorder Yes / No Cancer (list type) Yes / No Diabetes Yes / No Heart disease Yes / No Hernia or vaginal prolapse Yes / No Urinary problems Yes / No Other:
5 UROGYNECOLOGIC QUESTIONNAIRE I urinate every hours during the day. At night, I get up times to urinate. Do you lose urine in spurts with laughing, sneezing, or exertion?... Yes No What amount of urine do you lose?... Small Large Both In what position do you lose urine?... Sitting Standing Lying down Do you lose urine with a strong sense of urgency?... Yes No Does the sound, sight, or feel of running water make you lose urine?... Yes No Do you lose urine without any warning (without activity or urgency)?... Yes No Do you wear a pad all of the time?... Yes No Is it difficult to get the urine stream started?... Yes No Does your urine stream seem slow or weak?... Yes No Do you feel that you empty your bladder completely when you urinate? Yes No Do you have pain associated with urination?... Yes No Do you have frequent bladder infections?... Yes No Do you feel as if your pelvic organs are falling down?... Yes No Do you feel a bulge at the opening of your vagina?... Yes No BOWEL FUNCTION QUESTIONNAIRE Skip this section. I have no problems with my bowel function. I move my bowels times per day or times per week. Do you have difficulty emptying your rectum?... Yes No What is the consistency of your stool when this happens?... Liquid Soft Normal Hard Does it help to press on the inside or outside of the vagina?... Yes No Do you lose control of stool?... Yes No What is the consistency of your stool when this happens?... Liquid Soft Normal Hard Do you have problems controlling gas?... Yes No Do you have alternating constipation and diarrhea?... Yes No Do you have pain with bowel movements?... Yes No Do you ever see blood in your stools?... Yes No COSMETIC GYNECOLOGY QUESTIONNAIRE Skip this section. I have no problems with the appearance or function of my genital region I am self-conscious about the appearance of my vulva/vagina. Yes No I am unhappy with the way my vagina looks (i.e. gaping)... Yes No I am unhappy with the way my labia look (irregular, dark, long) Yes No My labia rub or pull on my clothing or during sex... Yes No I am unable to wear the type of clothing that I want. Yes No My vagina feels loose during sex. Yes No I have decreased sensation during sex.. Yes No I wish to enhance my pleasure with sex Yes No I want cosmetic vaginal surgery Yes No SEXUAL FUNCTION QUESTIONNAIRE Skip this section. I do not have any problems with my sexual functioning. Sexual orientation: heterosexual homosexual bisexual I have low desire to participate in sexual activity. Yes No I am unable to reach orgasm Yes No I have significant difficulty reaching orgasm.. Yes No I have a difficult time becoming aroused during sexual activity. Yes No I do not become sufficiently lubricated with sexual activity Yes No I experience pain with vaginal penetration... Yes No
6 BODY CONTOURING QUESTIONNAIRE Height Current Weight Goal Weight Are you interested in Body Contouring?... Yes No I have tried exercise and diet, but can not get rid of the unwanted fat Yes No I am unhappy with the appearance of my abdomen... Yes No I am unhappy with the appearance of my legs... Yes No I am unhappy with the appearance of my arms Yes No I dislike the appearance of fat when wearing a bra... Yes No I am unhappy with the appearance of my pubic area/ labia majora... Yes No DERMAL AESTHETIC QUESTIONNAIRE Do you have any concerns with the appearance of your skin?... Yes No Do you have any issues with Spider veins/varicose veins Yes No Do you have any Anti aging skin care concerns Yes No Do you want to learn more about Skin care products Yes No Do you have any issues with wrinkles or fine lines... Yes No Do you have any issues with Sun spots/age spots Yes No Do you have any concern with Aging/dull looking skin... Yes No Do you have any issues with Large pores/scars/skin texture... Yes No Do you have any concern with Flushing of the skin/redness... Yes No Do you have an interest in Laser Hair Removal If Yes, what areas: Yes No WEIGHT LOSS QUESTIONNAIRE Are you interested in a weight loss option?.. Yes Have you tried any weight loss programs in the past?...yes No No If Yes, which ones have you tried? Notes: For Office Use Only
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NEW PATIENT HISTORY Name Date of Birth Today s date Primary Care Physician Preferred Pharmacy Pharmacy address Phone _ Reason for today s visit Date of last menstrual period OB HISTORY NUMBER NUMBER NUMBER
Allan Warshowsky MD,FACOG, ABIHM. New Patient Questionnaire Date of appointment :
New Patient Questionnaire Date of appointment : Name: Address: Apt# City: State: Zip: Phone: Cell: Email: Age: DOB: Referred By: Your occupation: Allergies: To Medications: Other: Reason for Today s Visit:
Patient Information: Date: Last Name: Street Address: City: SS #: First Name: Sex: M F Birthdate: Contact Information:
Welcome to PHC Family Medicine! We know you have a choice and appreciate your choosing us to provide care to your family. Dr. Frankhouser will be asking about your concerns today, but so that we can learn
Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency.
GENERAL SURGICAL ASSOCIATES A practice of Lehigh Valley Physician Group Suite 208 ~ 1240 S. Cedar Crest Boulevard ~ Allentown, PA 18103 Phone: (610) 402-9780 PLEASE COMPLETE THIS FORM PRIOR TO YOUR VISIST
743 Jefferson Avenue Suite 203 Scranton, Pennsylvania
743 Jefferson Avenue Suite 203 Scranton, Pennsylvania 18510 570.344.9997 Name: DOB: / / Age: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Reason for your visit today: Who referred you
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.
NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM
NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM Today s Date: Name: Date of Birth: Race: American Indian or Alaskan Native Asian Black or African-American More
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES 13414 Medical Complex Drive, Suite 6 Tomball, TX 77375 281-516-0212 Welcome! We are glad that you have chosen Tomball Regional Internal Medicine Associates
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
IN CASE OF AN EMERGENCY NOT LIVING WITH YOU
GENERAL INFORMATION Name (as it appears on insur card) Address City State Zip Home phone Cell Email Marital status DOB SS# Employer Work # Parent name (if minor) IN CASE OF AN EMERGENCY NOT LIVING WITH
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
MEDICAL QUESTIONNAIRE (female)
MEDICAL QUESTIONNAIRE (female) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501 The appointment comprises of a discussion about this questionnaire and a subsequent medical examination.
Avery Acupuncture & Natural Medicine New Patient Registration
Welcome to Avery Acupuncture & Natural Medicine. Our goal is to make your experience here as comfortable as possible. If you have any questions, comments, concerns or suggestions, please let Veronica or
IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM.
Dr. Doug Scherr Date of Birth: Date: CHIEF COMPLAINT What is the main reason for your visit today? ALLERGIES Are you allergic to any of the following? Please check YES or NO for each. Check here if you
Health History Intake Form;
Health History Intake Form; Today s Date: Patient Name: Date of Birth: Age: Previous Primary Care Physician (if any): Phone: Address: Other Physicians involved in your care: Reason for visit today: Allergies
New Patient Intake Form
501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
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