PCCSS, LLP Pulmonary, Critical Care & Sleep Specialists
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- Brianna McCarthy
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1 NAME: AGE: DOB: DATE: REQUESTING PHYSICIAN: NOTE: Please help us find out about you by filling out the Patient side of this form on pages 1 3. If you don t know the answer to one of the questions, ask your bed partner if he/she can answer it for you. PLEASE LEAVE CLINICIAN SIDE BLANK. Why are you here to see a sleep specialist? Do you snore: Don t Know CC HPI If yes, is it loud? Don t Know How long ago did it start? Is it worsening? In which position do you snore? Back only All positions Is it worse on you back? Do you snore if you fall asleep in a chair? Does it disturb anyone? If yes, who? Has anyone ever noticed if you stop breathing in your sleep? Do you gasp or choke while you sleep? Do you suffer from either of the following in the morning? Dry mouth Headache
2 Do you feel sleepy during the daytime? Don t Know How many days per week? When did it start? Is it worsening? Don t Know How likely are you to doze off or fall asleep in the following situations? Please use the following scale: 1. Moderate chance of dozing 2. Slight chance of dozing 3. Moderate chance of dozing 4. High chance of dozing Sitting and reading EPWORTH SCORE: Watching television Sitting inactive in a public place While a passenger in a car without a break Laying 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 in traffic for a few minutes Are you being treated now or have been treated for any illness? PERSONAL, FAMILY, SOCIAL HISTORY 1. Past Med Hx Have you ever had any operations? Any injuries? Past Surg Hx Check if any close family member has: Family Hx Heart problems Diabetes Heartburn High Blood Pressure Cancer Other:
3 Marital Status S M W D Social Hx With whom do you live? What is your occupation? What are your leisure activities? What is your education level? Please circle any symptom you have, so we can find more about it: REVIEW OF SYMPTOMS Lack of energy; daytime sleepiness, trouble sleeping; Constitutional Snoring; loss of appetite; weight changes; fevers Eye problems, such as double or blurred vision; glaucoma; HEENT cataracts Hearing problems; buzzing or ringing in ears Allergies; hay fever Sinus problems Blood pressure or heart problems Cardiac Asthma; tuberculosis Pulmonary Stomach problems; heartburn; indigestion; Gastrointestinal change in bowel habits Urinary problems; frequency, infections; stones; bladder Genito Urinary Men: Prostate problems; night time urination Women: Abnormal menstrual periods; breast lumps; Female Reproductive could you be pregnant; recent mammogram, pap smear or pelvic exam Joint pains, swelling or redness; arthritis; back pain Musculoskeletal Muscle aches or tenderness; gout Rash, itching or other skin problems Dermatologic Paralysis (even temporary); numbness; loss of balance; Neurologic Seizures; loss of memory; headaches; stroke; Unusual thoughts; nervousness; crying or sadness; Psychiatric Suicide attempts; depression Thyroid disorder; diabetes; excess thirst or hunger; Endocrinologic Frequent urination Bleeding; easy bruising; risk factors for HIV; anemia; cancer Hematologic Others: Personally reviewed by me. I agree with or have amended its findings. Physician Signature
4 PHYSICAL EXAMINATION BP PULSE SpO2 RESP T GENERAL APPEARANCE N=Normal A=Abnormal D=Deferred Description of Abnormal Findings 1) NOSE: Mucosa Turbinates Septum 2) MOUTH: Mucosa Teeth Gums Tongue Pallate: Hard Soft Tonsils Posterior Pharynx 3) NECK: Appearance Symmetry Tracheal Position Crepitus Thyroid JVD 4) RESPIRATORY: Inspect Symmetry Percussion Palpation Auscultation Effort 5) HEART: Apex Heave Thrill Sounds Murmur Rub 6) ABDOMEN: Masses Tenderness Liver Spleen Bowel Sounds 7) LYMPH: Neck Axilla Groin Other (Specify) 8) MUSCULOSKELETAL/ NEUROLOGIC: Gait Station Strength Atrophy Tone Abnormal Movement 9) EXTREMETIES: Varicosities Edema Pulses Temp Tenderness Digits Nails 10) SKIN: Scars Rashes Describe 11) NEUROPSYCH: Oriented Mood New Patient Office Consult Bullet Points Bullet Points Bullet Points All Items with Gray Border and Item in each non Gray Border 99245
5 MEDICAL DECISION MAKING DATA REVIEWED: Lab (Date) Hemoglobin Electrolytes Other (Specify) Pulmonary Function Test (Date) Bronchoscopy (Date) Other (List/Date) X Rays (Date) Physician Interpretation: Chest CT Chest MRI Other (List Type) IMPRESSION: PLAN: F/U PFT/Spirometry V/Q Scan Chest X ray Nocturnal Pulse Oximetry Bronchoscopy Lab Pulm Risk Reduction CPEX Level 1 Level 2 Other Physician Signature
Patient Sleep History and Physical
Dear Patient, We appreciate your selection of this office to serve your medical and health needs and we will do all we can to provide you with the very best care. You must bring the following items with
ALLERGIES (food,latex,other)
MEDICATION LIST NAME: DOB: Main Phone: (CELL or HOME) Initials Consent to Import Medication History I give Dr. Heniff consent to import my medication history as provided by SureScripts. ALLERGIES (food,latex,other)
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
DESERT CENTER FOR ALLERGY AND CHEST DISEASES HEALTH QUESTIONAIRE NAME. PAST MEDICAL PROBLEMS- Check mark if you have any of the following
DESERT CENTER FOR ALLERGY AND CHEST DISEASES Pulmonary Medicine, Allergy/Immunology, Sleep Disorders Pulmonary Rehabilitation, Pulmonary Function Laboratory HEALTH QUESTIONAIRE NAME What is your presenting
New Patient Sleep Intake
New Patient Sleep Intake Name: Date of Birth: Primary Care Physician: Date of Visit: Referring Physician and/or Other Physicians: Retail Pharmacy: Mail Order Pharmacy: Address: Mail Order Phone #: Phone
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
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Sleep History Questionnaire
Sleep History Questionnaire Name: DOB: Phone: Date of Consultation: Consultation is requested by: Primary care provider: _ Preferred pharmacy: Chief complaint: Please tell us why you are here: How long
Sleep Center New Patient Questionnaire
For office use only Appt date: Sleep Center Clinician: Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 #1 respiratory hospital
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
EMORY SLEEP CENTER Sleep and Health Questionnaire
EMORY SLEEP CENTER Sleep and Health Questionnaire Demographics Today s Date: / / Name: Date of Birth: / / Address: Sex: Male Female City/State/Zip: Preferred Contact Number: Work Home Cell Occupation:
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely Date: email address: First name: Middle: Last: Nickname: Ethnicity/Race (please circle): Black or African American Caucasian Hispanic
Patient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )
Patient Information Name: Date of Birth: Age: Address: Number & Street City State Zip Code Home Number: ( ) Cell Number: ( ) Social Security Number: Marital Status: Religion: Race: Height: Weight: Sex:
Patient Intake Form for Allegany Ear, Nose, & Throat
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?
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
1960 FP CENTER FOR SLEEP DISORDERS
1960 FP CENTER FOR SLEEP DISORDERS Sleep Questionnaire Name: Date: Date of Birth: / / Age: Gender: Height: Weight: lbs. Referring Physician: Occupation: Please give a brief description of your sleep problem
Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History
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Sleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118
Sleep Questionnaire *Please complete the following as accurate as possible. Please bring your completed questionnaire, insurance card, photo ID, Pre-Authorization and/or Insurance referral form, and all
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE. Name: Date of Birth: / / Age: Sex: Address: City: Zip:
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE *Please bring copies of any recent Blood Work and Physician Sleep Referral Order* Please answer every question to the best of your
PATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:
SLEEP DISORDERS INSTITUTE HOSPITAL: DePaul Building Street Address City, State Zip Tel: (202) 555-1212 Fax: (202) 555-1212 SLEEP QUESTIONNAIRE PATIENT NAME: M.R. #: ACCT #: STREET ADDRESS: CITY: STATE:
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
Sleep Disorders Questionnaire
Sleep Disorders Questionnaire NAME: DATE: ADDRESS: DATE OF BIRTH: AGE: SEX: HOME PHONE: WORK PHONE: CELL PHONE: MARITAL STATUS: SINGLE: MARRIED: WIDOW(ER): DIVORCED: SEPARATED: REFERRING PHYSICIAN: ADDRESS:
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS NPSG CPAP CPAP Retitration Split Night PATIENT INFORMATION: Name: Last First Middle Initial Address: City: State: Zip: Social Security #: DOB: Gender: Age: Phone Number: Cell: Work:
PATIENT SLEEP QUESTIONNAIRE
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PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)
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Headache Follow-up Visit Form
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Room # Critical Care & Pulmonary Consultants, P.C.
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
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
Littleton, CO Welcome Packet 8151 Southpark Lane, Suite 200 Littleton, CO 80120
Littleton, CO Welcome Packet For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 8151 Southpark Lane, Suite 200, Littleton,
Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:
SUNSET SLEEP LABS PATIENT INFORMATION FORM Patient Information Name: Sex: M F Date of Birth: Address/Street: City: Zip: Phone: Alt Phone: Parent/Guardian: Phone: Social Security Number: Drivers License:
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
Questionnaire for Lipedema Patients
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PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
New Sleep Patient Questionnaire. Name Age Date. General Medical History 1. Please list any surgeries you have had and their approximate dates:
1 John S. Kim, M.D., Diplomate ABSM Lawrence A. Lynn, D.O., FCCP 1251Dublin Rd. Columbus, Ohio 43215 (614) 297-7704 (614) 297-7705 New Sleep Patient Questionnaire Name _ Age Date General Medical History
Denver, CO Welcome Packet
Fax: (303) 957-5414 or 720-542-8699 For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 1210 S Parker Road, Suite 101, Denver,
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
Sleep History Questionnaire B/P / Pulse: Neck Circum Wgt: Pulse Ox
2700 Campus Drive, Ste 100 2412 E 117 th Street Plymouth, MN 55441 Burnsville, MN 55337 P 763.519.0634 F 763.519.0636 P 952.431.5011 F 952.431.5013 www.whitneysleepcenter.com Sleep History Questionnaire
Sleep Medicine Questionnaire
Please bring this completed questionnaire with you to your sleep medicine appointment. Our sleep medicine staff strives to understand your sleep symptoms, which may be complex in nature. Thank you for
Pre-Test Questionnaire. Name: Sex: Age: Date of Birth: Height: ft. in. Weight: lbs Gain? Loss? of lbs over
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PEDIATRIC HISTORY FORM
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PLEASE INDICATE ANY OF THE FOLLOWING YOU ARE NOW EXPERIENCING:
DATE OF HEALTH HISTORY UPDATE: THIS IS A HEALTH HISTORY UPDATE. PLEASE INDICATE ANYTHING REGARDING YOUR HEALTH (MEDICAL AND DENTAL) THAT HAS CHANGED SINCE YOUR LAST VISIT TO OUR OFFICE. THANK YOU. WHAT
Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
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Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
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Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Wellness Visit Assessment
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Medical History Questionnaire
Medical History Questionnaire OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / Allergens No known allergens Iodine Plastic Antibiotics Latex Sedatives Aspirin Local anesthetics Sleeping pills
WELCOME TO OUR OFFICE
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Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name: Address: City:
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CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
Date of Birth: City: State: Zip: Home phone: Who is your primary care physician?
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Patient to complete this information
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COMPREHENSIVE NEW PATIENT QUESTIONNAIRE
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Sleep Questionnaire Patient's Name: Referring Dr.: Today s Date: DOB: Age: Marital Status: S M W D Gender: Occupation: Phone: Height: Current Weight: Weight 1 year ago: Weight 5 years ago: 5 yrs ago: 10
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PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
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PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
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ANY FAMILY HISTORY OF ANEURYSM OR DVT?
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Accredited Member Center of The American Academy of Sleep Medicine 400 Riverside Drive, Suite 1500, Bourbonnais, IL 60914 Phone (815) 933-2874 Fax (815) 939-9413 www.riversidemc.net/sleep General Information
UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT
APPLICANT NAME: UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT REACTION ACCOM. LIGHT PUPILS EQUAL UNEQUAL FUNDI FIELDS OF VISION COLOUR (TEST USED) WITHOUT GLASSES NEAR FAR WITH GLASSES RIGHT
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
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Sleep Disorders Center of Santa Maria
SLEEP QUESTIONNAIRE Patient Name: Sex: Date of Birth: Occupation: Usual Work Hours/Days: Referring Physician: Family Physician: Marital status: Single Married Divorced Widowed Please complete the following
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for