MRSA CLINIC OF MISSISSIPPI PATIENT HISTORY
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- Lizbeth Tyler
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1 MRSA CLINIC OF MISSISSIPPI PATIENT HISTORY Patient: DOB: Date of intake: Relation to other MSSA/MRSA patient: Active disease: Contact: Colonized: Positive staph cultures Patient MSSA/MRSA or Both Contact Dates Antibiotics : Dates: River Oaks Drive, Ste 303 Flowood, MS info@cide.ms
2 Past Medical History Serious medical illnesses : Illness that caused hospitalizati ons, disability, lasted for a prolonged period of time, prevented you from work or recreation fo r prolonged periods of time. (Circle none or list below) none Current medication: (Circle none or list below) none Allergies or intolerance to medications: ( Circle none or list below) none Operations : ( Circle none or list below) none River Oaks Drive, Ste 303 Flowood, MS info@cide.ms
3 Social Tobacco: (Circle which is correct) Never smoked Smoked but quit Still smoking Years smoked: Date of onset: Packs per day: Alcohol: (Circle which is corr ect ) Never Occasional Frequent DWI? Yes No Rehab for alcohol? Yes No Drinks per day: Educational level reached: River Oaks Drive, Ste 303 Flowood, MS info@cide.ms
4 Marital History Circle whi ch is correct: Divorced Never Married Widow or widower Number of times married: Health of current spouse: Family History Mother: Deceased age at death: Cause of death: Living Age: If living, state of current health: Father: Living Age: Deceased age at death: Cause of death: If living, state of current health: Siblings: Number of brothers: Number of sisters: Any deceased and cause of death: Diseases that run in your family: (Circle) Frequent Severe Any other health problems that run in the family: River Oaks Drive, Ste 303 Flowood, MS
5 Review of Systems This part of the questionnaire attempts to discover how all the various parts of your body are working. My health is: (Circle which is correct) Excellent Good Fair Poor If you circled fair or poor please give the major reason you selected that option: Skin All of us have minor skin problems. Please address boils or skin infections, or any skin cancers. Rashes: Malignancies: Other: Bone Muscle Joints Please comment and list any of the following: Rheumatism, arthritis, visits to a joint doctor either a rheumatologist or an orthopedist Are you taking medicine for arthritis? River Oaks Drive, Ste 303 Flowood, MS info@cide.ms
6 Joint replacements, if any: Date: Date: Date: Surgeon: Surgeon: Surgeon: Complication: Malignancies? Other: Endocrine: (Circle those that apply) DM Thyroid Other Extremities: (Circle those that apply) Ulcerations Vascular Problems Other River Oaks Drive, Ste 303 Flowood, MS
7 Blood: Clotting Problems WBC Problems RBC Problems Other HEET Ear, Nose, Throat: (Circle those that apply) Sinus Nose Bleed Oral Other Neck: Masses Other River Oaks Drive, Ste 303 Flowood, MS
8 Breast: Other Pulmonary: Pneumonia Tobacco TB Shortness of Breath Cardiac: (Circle those that apply) H BP Lipid Myocardial Disease Peripheral Vascular Disease Other River Oaks Drive, Ste 303 Flowood, MS info@cide.ms
9 Gastric Intestine: (Circle those that apply) GB Small Intestine Large Intestine Gastric Gastric Urinary: Infections Stones Other VD: STD River Oaks Drive, Ste 303 Flowood, MS
10 OB/GYN: NA Abnormal Pap Malignancies Neurological: Seizures CVA Other River Oaks Drive, Ste 303 Flowood, MS
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