Past Medical History. Chief Complaint: Appointment Date: Page 1
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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 Cochlear Implants Gum disease Sinus disease Cold sores (herpes infection) RESPIRATORY Asthma Emphysema (COPD) History of tuberculosis or positive PPD CARDIOVASCULAR Heart attack Congestive heart failure Pacemaker / defibrillator Heart murmur Artificial heart valve Rheumatic fever Deep venous thrombosis (blood clots) High blood pressure GASTROINTESTIONAL Hepatitis Liver disease Diabetes GENITOURINARY Kidney disease Bladder problem Prostate problem MUSCULOSKELETAL Artificial joint(s). If Yes, what year? Rheumatoid arthritis
2 Appointment Page 2 NEUROLOGIC Yes No Yes Details Stroke Seizure disorder Alzheimer s and/or dementia Deep brain stimulator HEMATOLOGIC History of cancer Anemia Anticoagulants / blood thinners ALLERGIC / IMMUNOLOGIC / INFECTIONS AIDS/HIV infection Autoimmune disease Prior Staph or MRSA infection Organ transplant recipient / immunosuppression Previous radiation therapy PSYCHIATRIC Severe anxiety or panic attacks Depression or bipolar disease Psychosis PERSONAL SKIN HISTORY Acne Eczema Psoriasis Lupus Skin cancer melanoma Skin cancer non melanoma Tanning bed use Blistering sunburn(s) Healing problems Keloid scars Surgical complication Abnormal moles Previous Mohs Surgery FAMILY SKIN HISTORY Please List Title Are you Adopted? Acne Eczema Psoriasis Yes No Title Family Member (Mother, Father, Grandmother, Grandfather, Brother, Sister, etc)
3 Appointment Page 3 FAMILY SKIN HISTORY (Continued) Yes No Title Family Member Skin cancer melanoma Skin cancer non melanoma Abnormal moles Healing problems Keloid scars Surgical complications PAST MAJOR SURGERY Yes No Yes Details Have you had any of the surgeries listed below? Heart Surgery Shunt/stent Pacemaker/Defibrillator Joint replacement Organ transplant SOCIAL HISTORY Yes No Do you use alcohol? If yes, Do you drink socially? Do you drink daily? Smoking Status Never Smoked Former Smoker Every Day Smoker Social Smoker Smoker, current status unknown Unknown if ever smoked Amount > pack a day < a pack a day Started Date Ended Date Occupation (select one) Disabled Employed Homemaker Retired Student Unemployed List occupation or former occupation: Other: Yes No Yes Details Performs strenuous work?
4 Appointment Page 4 Yes No Yes Details Have you had the flu shot Within the last year? Where? Are you allergic to flu shot? Are you allergic to eggs? Are you taking Coumadin/Warfarin? If yes, current INR result: Date of test: MEDICATIONS Please list Dosage Are you allergic to any medications? Yes No If yes, please list medications and how you react:
5 Appointment Page 5 Review of Systems Are you currently experiencing any of the following symptoms? YES NO Yes Details CONSTITUTIONAL Fevers / chills Weight loss or weight gain Fatigue Night sweats SKIN Painful, tender, red, crusty, bleeding or scaly lesion(s) Pigmented (darkly colored) lesion(s) Growths New or changing moles Rash EYES Tearing Burning Blurred vision Irritation EAR, NOSE AND THROAT Bloody nose Recurrent sinus infections or sinus disease Mouth ulcers or gum disease Sore throat RESPIRATORY Shortness of breath Cough Wheezing CARDIOVASCULAR Chest pain Leg swelling Leg pain with exercise Shortness of breath with exertion
6 Appointment Page 6 YES NO Yes Details GASTROINTESTIONAL Abdominal pain Nausea/vomiting Blood in stools (rectal bleeding) Black, tarry stools (melena) Diarrhea GENITOURINARY Blood in urine Pain with urination Difficult / frequent urination MUSCULOSKELETAL Muscle aches Pain in joints / arthritis LYMPHATIC / HEMATOLOGIC Enlarged lymph nodes Excessive bleeding / clotting problem NEUROLOGIC Tingling / burning sensations Numbness, loss of sensation Headache Weakness Light headedness or dizziness ALLERGIC / IMMUNOLOGIC / INFECTIONS Hay fever symptoms (sneezing; itchy, watery eyes) Active cold sore Chronic lymphocytic leukemia PSYCHIATRIC Severe anxiety Depression FEMALES Are you postmenopausal? Do you have abnormal menstrual bleeding? Are you pregnant? Due date: Breast feeding? Planning to become pregnant? Thank you for completing these important forms. A copy will be added to your medical record.
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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
FAMILY MEDICINE New Patient Medical History Form
FAMILY MEDICINE New Patient Medical History Form Personal History : Name: Date of Birth / / (mm/dd/yyyy) Age Occupation Birthplace (City&Country) Marital Status (check one): Single Married Divorced Separated
PLEASE COMPLETE ALL SECTIONS OF THIS FORM
PLEASE COMPLETE ALL SECTIONS OF THIS FORM Patient Name: Date of Birth: Referring Doctor? (Name, telephone number and address) Chief Complaint: Why have you come here? How did it start? What are the symptoms?
KAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM
KAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM Dr. Mr. Mrs. Ms. Miss New Patient or Returning Patient FULL LEGAL NAME: Reason for today s visit: Mohs Excision Skin Check other:
PATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
PATIENT INFORMATION Name: First Name MI Last Name Date of Birth: / / Sex: Male / Female / Declined SSN: Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Declined Marital Status: Single Married Divorced/Separated
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