LSOCA. Baseline Medical History. 8Baseline Medical HistoryBH504 Oct 07
|
|
|
- Darren Williams
- 5 years ago
- Views:
Transcription
1 8Baseline Medical HistoryBH504 Oct 07 Studies of Ocular Complications of AIDS Baseline Medical History LSOCA Purpose: Document medical history, physical exam, and symptoms. When: Baseline visit. By whom: Clinic coordinator and study physician. A. Clinic, patient, and visit identification 1. Clinic ID code: 2. Patient ID#: 3. Patient name code: 4. Date of visit: 5. Visit ID code: B L 6. Sequence number of this BH form First form completed on any one date is 01; if more forms are needed, number additional forms sequentially. B. Personal data 7. Date of birth: 8. Age: 9. Gender: s Male Female 10. Race/ethnicity (check only one): White, non-hispanic Black, non-hispanic Hispanic ( 3) Asian/Pacific Islander ( 4) American Indian/Alaskan Native ( 5) Other (specify): ( 6) 11. Highest formal education (check only one): formal education Grade 8 or less Grade 9, 10, or 11 ( 3) Grade 12 or high school graduate ( 4) Some college ( 5) College graduate ( 6) One or more s post college ( 7) 12. Current employment status (check only one): Disabled (unable to work) Employed with income Homemaker ( 3) Retired ( 4) Student ( 5) Unemployed ( 6) 13. Insurance status (check all that apply) a. Uninsured: b. Medicare: c. Medicaid: d. Veterans Administration: e. CHAMPUS: f. Private health insurance: 14. Type of private health insurance (check only one): Closed panel health care organization membership (no outside subspecialty referrals permitted except in exceptional circumstances) Insurer permits subspecialty referrals outside its organization with prior approval Patient may access subspecialty care without prior approval ( 3) Neither private health insurance nor Medicare/Medicaid HMO ( N) other ethnic group Revision 5 (04 Oct 07) de Baseline Medical History 1 of 8
2 C. Physical exam 15. Height (without shoes): inches centimeters 20. Specify the disease or condition that resulted in diagnosis of AIDS (index diagnosis) a. AIDS index diagnosis/condition: 16. Weight (without shoes): pounds kilograms /condition 17. Blood pressure (after 5 minutes resting) c. Date first diagnosed: a. Systolic: mmhg th b. Diastolic: mmhg D. HIV History 18. HIV-exposure category (check all that apply) a. MSM (sexual contact between men): b. Injecting-drug use: c. Hemophilia: d. Heterosexual contact: e. Transfusion recipient: f. Perinatal transmission: g. Other (specify): 21. Nadir CD4+ T-cell count a. Nadir CD4+ T-cell count documented in the medical records: b. Approximate date of nadir CD4+ T-cell count: th cells/ µl For item 22, enter in the first space greater than > or less than < when exact HIV RNA determination is not obtained (eg < ) otherwise enter Highest HIV RNA level ever documented: HIV exposure h. risk group reported: For items 20., , and refer to the HIV-related Diagnosis Code List in the SOCA General Handbook. 19. Date of HIV diagnosis: >/</0 copies/ml 23. Patient ever diagnosed with CMV disease (ocular or systemic): 28. Skip to item 28 after listing all CMV disease(s). th 24. CMV disease (#1) a. Location of CMV disease: c. Date of diagnosis: Revision 5 (04 Oct 07) de Baseline Medical History 2 of 8
3 25. CMV disease (#2): a. Location of CMV disease: 30. Other HIV-related disease (#2) c. Date of diagnosis: 26. CMV disease (#3) a. Location of CMV disease: c. Date of diagnosis: 31. Other HIV-related disease (#3) 32. Other HIV-related disease (#4) 27. CMV disease (#4) a. Location of CMV disease: 33. Other HIV-related disease (#5) c. Date of diagnosis: 28. Has the patient been diagnosed with other HIV-related diseases (other than CMV disease): 35. Skip to item 35 after listing all HIV-related disease(s). 34. Other HIV-related disease (#6) 29. Other HIV-related disease (#1) Revision 5 (04 Oct 07) de Baseline Medical History 3 of 8
4 E. Other medical history For each item 35. through 51., ask if the patient has ever been diagnosed with the following condition(s). Do not record disease already recorded under section D. 43. Tuberculosis: 44. Syphilis: 35. High blood pressure requiring medication: 45. Herpes zoster (specify location) 36. Patient diagnosed with hepatitis: 37. Type of hepatitis (check all that apply) a. Type A: b. Type B: c. Type C: d. Other (specify): location 46. Herpes simplex (specify location): location 47. Other dermatologic disease (specify): specify specify 37. Diabetes mellitus: If, date of diagnosis: th 38. Hyperlipidemia: If, date of diagnosis: th 39. Renal disease: 40. Hematologic disease: 48. Other diagnoses (specify): specify 49. Stevens-Johnson syndrome: a. Did conjunctival scarring ensue: Right 50. Left 50. Cardiovascular event (if, fill out CC form): 41. Seizure disorder requiring medication (specify): 51. Cerebrovascular event (if, fill out CC form): specify 42. Other neurologic disease (specify): Revision 5 (04 Oct 07) de Baseline Medical History 4 of 8
5 F. CMV syndromes questionnaire Answers to the following may be used to decide whether further evaluation for CMV disease is warranted. Positive responses should be reviewed with the study physician, who will determine what (if any) diagnostic tests need to be performed. Gastroenteritis/colitis/proctitis 57. Do you have any abdominal pain: Retinitis 52. Do you have any changes in the vision of either eye: 53. Is your vision blurred for both near and distant objects in either eye: 54. When you are looking at an object with only one eye, are there any blind spots: 55. Do you have floating spots in front of either eye: 56. a. Are they worse in the light: CMV esophagitis 58. Do you have diarrhea: a. Does it occur with abdominal pain: b. Is the diarrhea a large or small amount (check only one): 59. Large (more than 3 loose stools/) Small (less than or equal to 3 loose stools/) 59. Do you have any rectal pain: 60. Do you usually have to strain when you have a bowel movement: 61. Is there any blood and/or mucus with the stool: Hepatitis/cholangitis 56. Do you have any pain, burning or other discomfort with swallowing in your throat (neck) or in your upper chest, beneath the breast bone: 62. Do you have discomfort in the right upper part of your abdomen, including the area under your right ribs: 63. a. Is nausea or vomiting associated with this discomfort: 63. Do you have any fever: Revision 5 (04 Oct 07) de Baseline Medical History 5 of 8
6 Pneuitis Meningoencephalitis 64. Do you have shortness of breath: 69. Have you had any seizures: 65. Do you have a cough: a. Is it productive: Radiculomyelitis Do you feel unusually drowsy/weak/less alert than usual: 71. Have you had severe headache associated with neck stiffness and fever: 66. Do you have any decrease in leg or foot strength: 67. Do you have any loss of bowel or bladder control: 68. Do you have any numbness or altered sensation in your arms, legs or torso: 72. Do you have double vision: 73. Have you had any abnormal bodily movements (tremors, twitching, shaking, etc): Constitutional symptoms 74. Do you have the following symptoms: a. Generalized weakness: b. Fatigue or lethargy: c. Fever: d. Chills: e. Other (specify): general symptom Revision 5 (04 Oct 07) de Baseline Medical History 6 of 8
7 Study Physician: 75. Do any positive responses to questions lead you to make a presumptive diagnosis or prompt you to evaluate further: Specify diagnosis or testing indicated: 76. Instruction: If any of the above current symptoms lead to a probable or confirmed diagnosis, record the diagnosis on the Followup Medical History form (FH), section C, at the next visit. G. Cardiovascular/cerebrovascular risk factors 76. Cigarette smoking assessment a. Do you smoke cigarettes now: b. What is the average number of cigarettes you smoke each : Recreational drug use a. When was the last time you used cocaine (crack, nose candy, freebase) (check only one): Never less than 1 th Within 1-6 ths ( 3) Greater than 6 ths ( 4) Unknown ( 5) Refused ( 6) b. When was the last time you used methamphetamine (crystal meth) (check only one): Never less than 1 th Within 1-6 ths ( 3) Greater than 6 ths ( 4) Unknown ( 5) Refused ( 6) c. When was the last time you used isobutyl nitrite/amyl nitrite (poppers) (check only one): Never less than 1 th Within 1-6 ths ( 3) Greater than 6 ths ( 4) Unknown ( 5) Refused ( 6) cigarette(s)/ Revision 5 (04 Oct 07) de Baseline Medical History 7 of 8
8 H. Karnofsky score 78. Patient s Karnofsky score (See section in SOCA General Handbook relating to Karnofsky score; check only one): rmal; no complaints; no evidence of disease ( 10) Able to carry out normal activity; minor signs or symptoms of disease - 90 ( 09) rmal activity with effort; some signs or symptoms of disease - 80 ( 08) Cares for self; unable to carry on normal activity or to do active work - 70 ( 07) Requires occasional assistance but is able to care for most needs - 60 ( 06) Requires considerable assistance and frequent medical care -50 ( 05) Disabled; requires special care and assistance - 40 ( 04) Severely disabled; hospitalization is indicated although death is not imminent - 30 ( 03) Very sick; hospitalization necessary; active support treatment is necessary - 20 ( 02) Moribund; fatal processes progressing rapidly - 10 ( 01) I. Administrative information 79. Date form reviewed: 80. Study physician ID: 81. Study physician signature: 82. Clinic coordinator ID: 83. Clinic coordinator signature: Revision 5 (04 Oct 07) de Baseline Medical History 8 of 8
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
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
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:
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
Past Medical History. Chief Complaint: Appointment Date: Page 1
Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
HISTORY PAPERWORK FOR APPOINTMENTS WITH DAVID A. PROPST, D.O.
HISTORY PAPERWORK FOR APPOINTMENTS WITH DAVID A. PROPST, D.O. Name: Age: Room Number: Sex: MALE or FEMALE Dominant Hand: RIGHT or LEFT Height Weight Blood pressure HISTORY 1. Did your first symptoms begin
Please describe, in detail, when the symptoms began:
161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE Date Name (Last, First, M.I.) Address City State Zip Code Phone ( ) Work ( ) Cell ( ) Date of Birth Age Marital Status SSN Employer Employer
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
Initial History Form
William C. Gorospe, M.D., Ph.D. Sebastian R. Stanciu, M.D. Christina L. Bailey, M.D. Initial History Form Welcome to First Coast Infectious Disease Consultants, LLC. In order for us to get to know you
New Patient Information Form
New Patient Information Form Patient Label Dear Patient: Please take a few minutes to complete this form. Your answers will help the doctors and staff plan and provide your care. If you are unsure of any
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.
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
New Patient Specialty Intake Form Department of Surgery
This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
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
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight:
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight: I Referring Doctor Complete Name of Referring Doctor Last Complete Address
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:
Personal Health Risk Appraisal
Today s Date: Premier Arthritis and Osteoporosis Center 722 North Fairfield Road Beavercreek, OH 45434 Phone (937) 208-7000 Fax (937) 208-7010 Personal Health Risk Appraisal Last Name: First Name: MI:
Patient Health Questionnaire
Patient Health Questionnaire Demographics Patient Title (check one): Mr. Mrs. Miss Dr. Prof. Rev First Name: Middle Name: Last Name: Suffix: Address: City: State: Zip Code: Date of birth: Age: Cell Phone:
Patient Interview Form
Page 1 of 6 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Race Select
NEW PATIENT HISTORY FORM. Are you diabetic? YES NO Diabetic Physician:
NEW PATIENT HISTORY FORM NAME Personal Health History Are you diabetic? YES NO Diabetic Physician: What Type of Diabetes Do You Have? DATE How long have you had diabetes? Do You Have Hepatitis? YES NO
Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire
Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire Please complete this questionnaire before your scheduled appointment and bring this form with you the day of your visit. Patient
OU Children s Physicians Pediatric Arthritis Center
Please complete the following questionnaire for your child: Patient Name: Birth Date: Parent/Caretaker Name: Primary Care Physician (Full Name, City, & State) Mother s Occupation: Fathers Occupation: Name
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:
PATIENT INFORMATION (PLEASE PRINT) SOC SEC #: - - MRN#: Home Phone: Work Phone: Ext: Address: City: Cell Phone: Date of Birth: - - Age: yrs State: Zip Code: Employer: SEX: Male Female Work Address: City:
NEW PATIENT INFORMATION
OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
Allina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
SANTA MONICA BREAST CENTER INTAKE FORM
SANTA MONICA BREAST CENTER Who referred you to see us today? Who is your primary care physician? Are there any other MDs who you would like to receive today s visit information? No Yes MD contact info
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)
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
Today s Date: Pt Initials: PATIENT INFORMATION. First Name: Last Name: Middle Name: Date of Birth: Social Security #: Preferred Language:
PATIENT INFORMATION First Name: Last Name: Middle Name: Suffix: Nickname: Male Female Date of Birth: Social Security #: Preferred Language: Race: Asian Native Hawaiian Other Pacific Islander Black / African
Dr. Hall New Patient Paperwork Please fill out these forms completely
Dr. Hall New Patient Paperwork Please fill out these forms completely Date of Appointment Complete the enclosed packet and bring it to the appointment along with all X Rays, MRI disc and reports. Please
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
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
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name:
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
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
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?
I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
Baylor Physical Medicine and Rehabilitation NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny Dear Patient: Please complete this questionnaire before you come for your appointment. Be sure to call us as soon
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY NAME: _ DATE: Please complete the following questionnaire as completely as possible. 1. MEDICAL HISTORY Please list all current and prior health problems,
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
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
Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider
Spine New Patient Questionnaire Rev
Spine New Patient Questionnaire Rev 10.13.10 Name: Male Female Temp: Height: Weight: Date of Visit: Date of Birth: Age Today: *Please note this is a multi-part questionnaire. When you are done, please
San Francisco Ear Nose & Throat Medical Group, Inc
SF ENT San Francisco Ear Nose & Throat Medical Group, Inc Adult & Pediatric Otolaryngology Hearing Disorders Endoscopic Sinus Surgery Head & Neck Surgery Thomas L. Engel, M.D. Vanessa R. Erickson, M.D.
Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:
Tel: (312) 694-7337 Women s Integrated Fax: (312) 695-0156 Pelvic Health Program 1.0: Basic Information Date of Birth: / / Age: Home Address: Preferred Language: English Spanish Other: Email address: Preferred
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
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
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:
ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: 403.243.8114 Fax: 403.212.0880 Full Name: Address: City: Province: Postal Code: Date of Birth (MM/DD/YYYY): Home Phone:
Blue Precision HMO Annual Health Assessment Form - Adult
BCBSIL Subscriber ID: Name of Physician: Blue Precision HMO Annual Health Assessment Form - Adult Reason(s) for Visit: Date of Service: Medications: Name of Medication Dosage Frequency Comments Allergies:
WEIGHT LOSS PATIENT INFORMATION RECORD
WEIGHT LOSS PATIENT INFORMATION RECORD PLEASE BRING THIS COMPLETED FORM TO YOUR APPOINTMENT Date: / / Last Name: First: MI: Date of Birth: / / Sex: Age: Home Phone: ( ) Mobile Phone: ( ) Address: City:
Name. Date of Birth. Primary Care Doctor? Who is the Doctor that referred you to us? Name of person completing this form?
Orthopaedic Surgical Oncology of Arizona Dr Bruce A Mallin Dr Matthew J Seidel PATIENT HISTORY FORM To help us better understand your risk factors for cancer, please complete this medical history. Please
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
Rupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?
PATIENT INFORMATION NAME DATE ADDRESS CITY STATE ZIP HOME # CELL # WORK # E MAIL ADDRESS SOCIAL SECURITY # I WOULD LIKE TO RECEIVE EMAIL APPOINTMENT REMINDERS [YES] [NO] RACE: AMERICAN INDIAN ALASKA NATIVE
DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM
Name: MR#: Date: DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM Referring Physician s Name: Primary Care Provider s Name: 1. What was/were your first movement disorder symptoms? What did you
Cascadia Chiropractic Centre
Name: Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: Date of Birth: Your age: Care Card #: Address: City/Prov: Postal Code: Phone: Cell: Work Phone: E-mail Address: Marital
Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
Eastern Shore MediCann Clinic, LLC
Eastern Shore MediCann Clinic, LLC New Patient Medical History and Intake Form Medical Marijuana Certification Name Date of Birth Social Security Number Gender: Male Female Address: Street: City: State
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
GASTROCARE, P.C. Contact Preference: HOME: Cell #: Office #: REASON FOR VISIT: Allergies: Current Medications (Name/Dose/How taken):
GASTROCARE, P.C. DR. A.B. REDDY, M.D., F.A.C.G. DR. REKHA KHURANA, M.D. Referring Physician: First Name: Date of Birth: Last name: Age: Pharmacy (include location): Fax Number: Email Address: Gender: Male
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
NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
Who is filling out this intake form? Self Spouse Parent Guardian
Office Use Only: Reviewed with Patient Data Entry Scan & File Date: Date: Date: Initials: Initials: Initials: Today s Date: Who is filling out this intake form? Self Spouse Parent Guardian If you are not
BACK AND NECK PAIN QUESTIONNAIRE
Neurological Surgery and Spine Surgery, S.C. 1 Westbrook Corporate Center, Suite 800 Westchester, Illinois 60154 BACK AND NECK PAIN QUESTIONNAIRE Please PRINT all information CLEARLY and answer all questions
Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
GENERAL INFORMATION HISTORY QUESTIONNAIRE Name: Today s Date: Age: Date of birth: Sex: M F SS#: Home Address: Cell Phone: Your doctor: Home Phone: Your Attorney (if any): If questions arise after today
History Form for Exceptional Home-Based Care
Patient Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best care possible
Neurosurgery Clinic. I, hereby acknowledge, that I am not pregnant and understand the risks of having ionizing radiation. Date. Signature.
Name Chart # Neurosurgery Clinic I, hereby acknowledge, that I am not pregnant and understand the risks of having ionizing radiation. Date Signature X-ray Tech PATIENT INFORMATION FORM Name LAST FIRST
PRE-EMPLOYMENT PHYSICAL - INALFA
Page 1 of 5 PRE-EMPLOYMENT PHYSICAL - INALFA Patient Name Date of Birth Please Circle: Gender Male Female Marital Status: Single Married Divorced Widowed Address City State Zip Code Home Phone Cell Phone
Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother
Silver Child Development Center New Patient Questionnaire Today s Date Mother s Name First Last Date of Birth Relation (circle) Biological Mother Stepmother Adoptive Mother Foster Mother Other Father s
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
Welcome to the UCLA Center for East- West Medicine Primary Care
Instructions: Welcome to the UCLA Center for East- West Medicine Primary Care We ask a lot of questions because we really want to get to know you! Please take your time with the paper work and return it
In case of emergency, please notify:
Name: First Name Middle Initial Date: Last Name Mailing Address: City State Zip: Social Security #: Age: Sex: Male Female Height: Work Phone: ( Birth Date: Home Phone: ( Weight: Cell Phone: ( Email Address:
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
MEDICAL QUESTIONNAIRE (male)
MEDICAL QUESTIONNAIRE (male) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501/502 Fax: 01 2780248 The appointment comprises of a discussion about this questionnaire and a subsequent
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.
ACUPUNCTURE QUESTIONNAIRE
ACUPUNCTURE QUESTIONNAIRE CHIEF COMPLAINT: PAIN EVALUATION Pain Scale: no pain 0 1 2 3 4 5 6 7 8 9 10 severe pain 1 Mark each area where you are having pain according to the pain scale above. HISTORY HEALTH
For the Patient: Rituximab injection Other names: RITUXAN
For the Patient: Rituximab injection Other names: RITUXAN Rituximab (ri tux' i mab) is a drug that is used to treat some types of cancer. It is a monoclonal antibody, a type of protein designed to target