MEDICAL HISTORY FORM FOR FOLLOW-UP
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1 MEDICAL HISTORY FORM FOR FOLLOW-UP ID NUMBER: 0a) Date of Collection / / 0b) Staff Code Instructions: Whenever numerical responses are required, enter the number so that the last digit appears in the rightmost box. Enter leading zeroes where necessary to fill all boxes. Notes: Sub scripts in blue represent the comparable SPIROMICS I variable (i.e. variable 5ko). Sub scripts in red represent the response coding in the SPIROMICS II CDART2 database (i.e. No0) This questionnaire includes questions about your medical history. This will help us better understand how various medical conditions relate to COPD. 1) Did you get an influenza vaccination (flu shot) in the last 12 months? No 0 2a) Did you get a pneumonia vaccination in the last 5 years? No 0 Go to 3 Don t know 2 Go to 3 2b) If Yes, which vaccination did you receive? Pneumovax (PSV-23) 1 Provnar (PSV-13) 2 Both 3 Don t know 4 3) Have you been diagnosed with alpha-1 anti-trypsin deficiency? No0 Don t know 2 Have you seen a physician or other medical provider for any of the following problems since your last SPIROMICS visit? 4) Eyes, ears, nose, throat No 0 If Yes, please explain: a) Vision problems 4a1) b) Hearing problems 4b1) c) Dizziness 4c1) Medical History Form for Follow-up, MHF Page 1 of 7
2 No 0 If Yes, please explain: d) Ears ringing 4d1) e) Sinusitis/rhinitis 4e1) f) Other 4f1) 5) Cardiovascular No 0 If Yes, please explain: a) High blood pressure 5a1) b) Coronary artery disease 5b1) c) Angina (chest pain) 5c1) d) Heart attack 5d1) e) Murmur 5e1) f) Palpitations, irregular 5f1) heartbeat g) Valve disease 5g1) h) Congestive heart failure 5h1) i) Blood clots 5i1) j) Poor circulation 5j1) (claudication) k) Heart surgery for valve replacement 5k1) l) Heart surgery for bypass 5l1) m) Heart procedure for blockage (stent or balloon) 5l1) n) Heart procedure for pacemaker or abnormal heart rhythm 5n1) 5ko) Other 5k15o1) 6) Gastrointestinal No 0 If Yes, please explain: a) Esophageal condition 6a1) or disease b) Ulcers 6b1) c) Hepatitis or jaundice 6c1) d) Crohn s disease or colitis 6d1) e) Gallstones 6e1) f) Cirrhosis 6f1) g) GERD (heart burn) 6g1) h) Hiatal hernia 6h1) i) Other 6i1) Medical History Form for Follow-up, MHF Page 2 of 7
3 7) Pulmonary/vascular No 0 If Yes, please explain: a) Intubation or respirator 7a1) b) Pneumothorax 7b1) (collapsed lung) c) Tuberculosis 7c1) d) Pulmonary fibrosis 7d1) e) Lung nodules 7e1) f) Pulmonary embolism or blood clot in lung 7f1) 7hg) Wedge Resection (surgery to remove part or all of the lung) 7h17g1) h) Biopsy of lung with surgery or procedure 7h1) 7gi) Other 7g17i1) 8) Oncology/hematology No 0 If Yes, please explain: a) Cancer (except basal 8a1) cell skin cancer) b) Anemia 8b1) c) Other 8c1) 9) Genitourinary and reproductive No 0 If Yes, please explain: a) Menstrual symptoms 9a1) b) Enlarged prostate or BPH 9b1) (men) c) Bladder or kidney 9c1) problems/ kidney stones d) Other 9d1) 10) Endocrine No 0 If Yes, please explain: a) Diabetes 10a1) b) Thyroid 10b1) c) Other 10c1) 11) Neurology No 0 If Yes, please explain: a) Stroke 11a1) b) Headaches 11b1) c) Seizure 11c1) d) Other 11d1) Medical History Form for Follow-up, MHF Page 3 of 7
4 12) Muscular/skeletal No 0 If Yes, please explain: a) Rheumatoid arthritis 12a1) b) Gout 12b1) c) Osteoporosis 12c1) d) Fractures 12d1) e) Joint pain 12e1) f) Osteoarthritis 12f1) g) Other 12g1) 13) Dermatology No 0 If Yes, please explain: a) Rashes/hives/eczema 13a1) b) Psoriasis 13b1) c) Shingles 13c1) d) Other 13d1) 14) Infectious disease No 0 If Yes, please explain: a) Atypical mycobacteria 14a1) (MAC, MAI) b) Fungal disease 14b1) c) Other 14c1) 15) Psychiatric No 0 If Yes, please explain: a) Anxiety 15a1) b) Depression 15b1) c) Other 15c1) 16) Other significant problems No 0 If Yes, please list: not reported in questions a1) 16b1) 16c1) 16d1) 16e1) Questions have been removed. Medical History Form for Follow-up, MHF Page 4 of 7
5 Now I am going to ask you some questions about your use of alcoholic beverages during the past year. By alcoholic beverages I mean beer, wine, vodka etc. 24a) How often do you have a drink containing alcohol? Go to 32a Monthly or less 1 2 to 4 times per month 2 2 to 3 times per week 3 4 or more times per week 4 25a) How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or or or 6 2 7, 8, or or more 4 26a) How often do you have six or more drinks on one occasion? If the Total Score for 25a and 26a = 0, Go to 32a 27a) How often during the last year have you found that you were not able to stop drinking once you had started? 28a) How often during the last year have you failed to do what was normally expected from you because of drinking? 29a) How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Medical History Form for Follow-up, MHF Page 5 of 7
6 30a) How often during the last year have you had a feeling of guilt or remorse after drinking? 31) How often during the last year have you been unable to remember what happened the night before because you had been drinking? 32a) Have you or someone else been injured as a result of your drinking? No 0 Yes, but not in the last year 2 Yes, during the last year 4 33) Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? No 0 Yes, but not in the last year 2 Yes, during the last year 4 IF participant is MALE, Go to End IF participant is FEMALE, Continue with 34 34) Have you reached menopause? No0 Don t know 2 Question 35 has been removed. Medical History Form for Follow-up, MHF Page 6 of 7
7 36) Did you ever use oral contraceptive medications? No 0 Go to 38 37) If you did use oral contraceptives, for how many years? years 38) Did you ever use hormone replacement therapy? No 0 Go to 43 39) If you did use hormone replacement therapy, for how many years? years Questions have been removed. 43) In the last 12 months have you had an ovary removed? No 0 Go to End 44) If you had an ovary removed, was one removed or both? One 1 Both 2 45) At what age was your ovary or ovaries removed? years old END OF FORM Medical History Form for Follow-up, MHF Page 7 of 7
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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
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
*** ADDRESS: (If address is not provided, you MUST write Patient denied.)
PATIENT INFORMATION NORTHWEST BROWARD ORTHOPAEDICS DATE: ***E-MAIL ADDRESS: (If e-mail address is not provided, you MUST write Patient denied.) Pharmacy Name: Pharmacy Phone Number: Pharmacy Location PATIENT
Health History Questionaire
Patient DOB: Patient Name: Date: Health History Questionaire Who referred your consultation? If no one referred you, how did you hear about us? Who is your primary care physician? Have you ever seen a
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD
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MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
Mailing Address: Street City Zip
First Middle Last Mailing Address: Primary Phone: Street City Zip Secondary Phone: Date of Birth: Male Female SSN: Emergency Contact Phone: Marital Status: Single Race: American Indian or Alaska Native
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