PATIENT HEALTH INFORMATION SHEET
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- Karen Hodge
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1 . 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: ADDRESS: PHONE: INSURANCE: PRIMARY CARE PHYSICIAN: REFERRING PHYSICIAN: SURGEON (IF APPLICABLE): PAST & CURRENT MEDICAL PROBLEMS HOSPITALIZATIONS & OPERATIONS (APPROXIMATE DATES & LOCATIONS)
2 Date: YOUR MEDICATION RECORD Name: DOB: Phone: Address: Primary Dr: Allergies and reactions caused: Have you had a Flu shot? Yes No When Have you had a Pneumonia shot? Yes No When List your medicines, herbal, vitamins/supplements and over the counter medicines Medication Name Dose Frequency Your preferred pharmacy is: Store #: Street Address: City: Phone Number: By signing this you are consenting to participate in electronic prescribing, which allows the doctors access to your pharmacy and prescription information. X
3 FAMILY HISTORY FAMILY MEMBER AGE HEALTH PROBLEMS FATHER MOTHER IF DECEASED/AGE & CAUSE OF DEATH HOW MANY SISTERS? HOW MANY BROTHERS? CHILDREN ANY FAMILY MEMBER WITH CANCER OR BLOOD PROBLEM? RELATIONSHIP: CANCER TYPE/BLOOD PROBLEM: RELATIONSHIP: CANCER TYPE/BLOOD PROBLEM: SOCIAL HISTORY CIRCLE ONE: SINGLE MARRIED DIVORCED WIDOWED PLACE OF BIRTH: PERMANENT RESIDENCE: YOUR CURRENT OR PREVIOUS OCCUPATION: SPOUSE S AGE & CURRENT OR PREVIOUS OCCUPATION: HOW MANY YEARS IN FLORIDA: EVER USE TOBACCO? YES NO EVER DRINK ALCOHOL? YES NO WHAT TYPE? CIGARETTES CIGAR PIPE OTHER CURRENT PAST HOW MUCH? HOW LONG? HOW MUCH? WHEN QUIT? HOW FREQUENT? EVER 6 OR MORE DRINKS ON ONE OCCASION? YES/NO EVER EXPOSED TO RADIATION, TOXINS, CHEMICALS OR ASBESTOS? YES NO WHEN & WHERE?
4 SYSTEMIC REVIEW PAIN ASSESSMENT CHOOSE THE FACE THAT BEST DESCRIBES HOW YOU FEEL PLEASE CIRCLE YES OR NO IF EVER HAD PROBLEM OR IS A CURRENT PROBLEM. HEMATOLOGIC: EMOTIONAL: BLOOD DISEASE NO YES SEEN A PSYCHIATRIST NO YES ANEMIA NO YES DEPRESSION NO YES DIFFICULTY HEALING NO YES THOUGHTS OF SUICIDE NO YES SWOLLEN LYMPH GLANDS NO YES SLEEP TROUBLE NO YES BLOOD CLOTS NO YES APPETITE CHANGE NO YES PLATELET PROBLEMS NO YES ANXIETY ATTACKS NO YES ABNORMAL BRUISING NO YES ABNORMAL BLEEDING NO YES GYNECOLOGICAL: HEAVY SURGICAL BLEEDING NO YES HEAVY PERIODS NO YES HEAVY NASAL BLEEDING NO YES APPROX. AGE PERIOD STARTED: HEAVY GUM BLEEDING NO YES APPROX. LAST PERIOD: BLOOD TRANSFUSIONS NO YES NUMBER OF PREGNANCIES: HOW MANY? WHEN MISCARRIAGES OR ABORTIONS: DATE OF LAST PAP SMEAR: IMMUNITY: DATE OF LAST MAMMOGRAM: FREQUEST COLDS NO YES BREAST SELF EXAMS NO YES ALLERGIES TO DUST/POLLEN NO YES SERIOUS INFECTIONS NO YES IMMUNE DISORDER AIDS/HIV NO YES AUTOIMMUNE DISEASE NO YES COMMENTS:
5 PLEASE CIRCLE YES OR NO IF EVER HAD PROBLEM OR IS A CURRENT PROBLEM. GENERAL: GASTROINTESTINAL: HEALTH GOOD? NO YES CONSTIPATION NO YES RECENT WEIGHT CHANGE NO YES DIARRHEA NO YES UNEXPLAINED FEVERS NO YES VOMITING NO YES NIGHT SWEATS NO YES VOMITING BLOOD NO YES SLEEP TROUBLE NO YES ULCER NO YES CHANGE IN APPETITE NO YES RECTAL BLEEDING NO YES GALLBLADDER TROUBLE NO YES SKIN: HEPATITIS/JAUNDICE NO YES SKIN PROBLEMS NO YES HEARTBURN NO YES DO YOU USE SUNSCREEN NO YES BLACK STOOL NO YES RASH NO YES CHANGE IN BOWEL HABITS NO YES SKIN CANCER NO YES PENCIL SHAPE STOOLS NO YES SKIN EXAMS NO YES CRAMPING NO YES HEAD & NECK: HEMORRHOIDS NO YES CATARACTS NO YES DATE OF LAST COLONOSCOPY: GLAUCOMA NO YES SINUS TROUBLES NO YES GENITOURINARY: HOARSENESS NO YES LOSS OF URINE NO YES EAR/HEARING TROUBLE NO YES FREQUENT URINATION NO YES TROUBLE SWALLOWING NO YES BURNING URINATION NO YES BLOOD IN URINE NO YES ENDOCRINE: PAINFUL URINATION NO YES THYROID PROBLEMS NO YES KIDNEY PROBLEM NO YES DIABETES NO YES KIDNEY STONES NO YES BIRTH CONTROL PILLS NO YES DIALYSIS NO YES ESTROGEN REPLACEMENT NO YES DO YOU GET A ROUTINE PSA NO YES RESPIRATORY: NEUROLOGICAL: PNEUMONIA NO YES NUMBNESS/WEAKNESS NO YES TUBERCULOSIS NO YES STROKE OR TIA NO YES COUGHING BLOOD NO YES SEIZURES NO YES CHRONIC COUGH NO YES FAINTING SPELLS NO YES ASTHMA NO YES PARALYSIS NO YES EMPHYSEMA NO YES DIZZINESS NO YES SHORTNESS OF BREATH NO YES MEMORY LOSS NO YES CONFUSION NO YES CARDIOVASCULAR: HEADACHES/MIGRANES NO YES HEART ATTACKS NO YES MUSCULOSKELETAL: CHEST PAIN/ANGINA NO YES JOINT PAIN NO YES HIGH BLOOD PRESSURE NO YES BONE PAIN NO YES LEG SWELLING NO YES ARTHRITIS NO YES SLEEP APNEA/SNORING NO YES GOUT NO YES RHEUMATIC FEVER NO YES OSTEOPOROSIS NO YES ABNORMAL RHYTHM NO YES ABNORMAL CHOLESTEROL NO YES
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Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Email Address: Date of Birth: Marital Status: Married Separated Divorced
WHEN WAS YOUR LAST TEST OR IMMUNIZATION? PLEASE LIST PAST ILLNESSES, OPERATIONS, HOSPITALIZATIONS YOU HAVE HAD: TYPE: DATE TYPE: DATE
NAME: DATE: DOB: REFERRD BY: REASON FOR VISIT: ROUTINE PHYSICAL PROBLEM DESCRIBE PROBLEM: AGE: CHECK IF YOU HAD ANY OF THESE MEDICAL PROBLEMS IN THE PAST MAJOR ILLNESSES YES NO YES NO Anemia Hepatitis
HD CLINIC MEDICAL HISTORY FORM
HD CLINIC MEDICAL HISTORY FORM Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the questions below as best as you can. If you need assistance, a caregiver/companion
Broward Oncology Associates, P.A. PATIENT INFORMATION
NAME: BIRTHDATE: AGE: LOCAL ADDRESS (Street city state zip): HOME TELEPHONE# CELL # SOCIAL SECURITY #: - - SEX MARITAL STATUS WHAT IS YOUR HT? WHAT IS YOUR WT? EMPLOYER WORK# SPOUSE'S NAME SPOUSE'S EMPLOYER
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care
Patient Health History
Patient Health History This information is very important in your care. Please complete as carefully and accurately as possible. Name: Date: Height: inches Weight: lbs Age: Symptoms: 1. Type of symptoms
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)