NEW PATIENT INTAKE FORM
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1 NEW PATIENT INTAKE FORM NAME: DOB: SEX: MALE FEMALE ADDRESS: ZIP CODE: PHONE #: - - WORK#: - - PHARMACY: PHARMACY #: - - WOULD YOU BE INTERESTED IN HAVING ACCESS TO YOUR MEDICAL RECORDS ONLINE? YES / NO REFERRED BY: IS THIS YOUR PRIMARY CARE DOCTOR? YES / NO IF NOT, WHAT IS THE NAME OF YOUR PRIMARY CARE DOCTOR? EMERGENCY CONTACT NAME: PHONE #: - - IS THIS YOUR: PARENT CHILD SPOUSE FRIEND OTHER: ARE YOU A CURRENT SMOKER? YES / NO ARE YOU A FORMER SMOKER? YES / NO WHEN DID YOU QUIT? HAVE YOU HAD A PNEUMONIA VACCINE? YES / NO HAVE YOU RECEIVED YOUR FLU VACCINE THIS SEASON? YES / NO DO YOU HAVE ANY ALLERGIES TO MEDICATIONS? YES / NO IF YES, PLEASE LIST:. DO YOU TAKE ANY MEDICATIONS, VITAMINS, HERBS OR SUPPLEMENTS? YES / NO NAME OF MEDICATION STRENGTH FREQUENCY
2 1. HOW OFTEN DID YOU HAVE A DRINK CONTAINING ALCOHOL IN THE PAST YEAR? Never Monthly or less 2-4 times/month 2-3 times/week 4 or more times/week 2. HOW MANY DRINKS DID YOU HAVE ON A TYPICAL DAY WHEN YOU WERE DRINKING IN THE PAST YEAR? 1-2 Drinks 3-4 Drinks 5-6 Drinks 7-9 Drinks 10+ Drinks 3. HOW OFTEN DID YOU HAVE 6 OR MORE DRINKS ON ONE OCCASION IN ONE YEAR? Never Less than monthly Monthly Weekly Daily MEDICAL HISTORY PAST OR CURRENT CONDITIONS FOR THE PATIENT: ALLERGIES/HAY FEVER HIGH BLOOD PRESSURE ASTHMA ECZEMA LUNG DISEASE INFECTIOUS DISEASE IMMUNE DISEASE DIABETES LIVER DISEASE KIDNEY DISEASE NEUROLOGICAL DISEASE HIGH CHOLESTEROL CANCER CARDIOVASCULAR DISEASE OTHER: FAMILY HISTORY PAST OR CURRENT CONDITIONS FOR FAMILY MEMBERS: MOTHER FATHER CHILDREN MATERNAL GRANDMOTHER PATERNAL GRANDMOTHER MATERNAL GRANDFATHER PATERNAL GRANDFATHER SIBLINGS
3 REVIEW OF SYMPTOMS WHAT IS THE REASON FOR YOUR VISIT TODAY? IN THE LAST 2-4 WEEKS, HAVE YOU EXPERIENCED ANY OF THE FOLLOWING: EARS Ear Pain Ear Drainage Ear Itching NOSE Runny Nose Itching Nose Sneezing Nose Bleeds Post Nasal Drips Nasal Congestion THROAT Sore Throat Throat Itching Throat Swelling Tongue Swelling NEUROLOGICAL Headache Weakness in Limbs Numbness Weight Loss EYES Eye Itching Eye Redness Eye Swelling Eye Drainage Vision Changes RESPIRATORY Shortness of Breath Wheezing Chest Tightness Sputum Cough HEME/LYMPH Easy Bruising Easy Bleeding Enlarged Lymph Nodes CARDIOVASCULAR Chest Pain Palpitations Difficulty Laying Flat GASTROINTESTINAL Abdominal Pain Vomiting Diarrhea Heartburn SKIN Itching Rash Hives Swelling Eczema GENERAL Fever Chills Night Sweats Weight Gain MUSCULOSKELETAL Joint Swelling Joint Pain Joint Stiffness
4 ONLY IF YOU ARE EXPERIENCING SYMPTOMS OF THE EYES & NOSE Mini-Juniper: Circle the number that best describes how troubled you have been in the past 2-4 weeks with your symptoms. 0 = Not at all 1 = Hardly 2 = Somewhat 3 = Moderate 4 = Quite A Bit 5 = Very 6 = Extremely ACTIVITIES Regular Activities at Home, Work or School Recreational Activities or Hobbies Sleep PRACTICAL PROBLEMS Need to Rub Eyes or Nose Need to Blow Nose Repeatedly NOSE SYMPTOMS Sneezing Stuffy/Blocked Nose Runny Nose EYE SYMPTOMS Itchy Eyes Sore Eyes Watery Eyes OTHER SYMPTOMS Tiredness/Fatigue Thirst Feeling Irritable
5 ASTHMA CONTROL TEST ONLY IF YOU HAVE ASTHMA, COMPLETE THIS FORM! Please circle which number applies to you for the following questions. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at home, work and school? 1=all of the time 2=most of the time 3=some of the time 4=little of the time During the past 4 weeks, how often have you had shortness of breath? 1=more than once a day 2=once a day 3=three to six times a week 4=once or twice a week During the past 4 weeks, how often did your symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? 1=four or more nights a week 2=two or three nights a week 3=once a week 4=once or twice a month During the past 4 weeks, how often have you used your rescue inhaler or nebulizer machine? 1=three or more times a day 2=one or two times a day 3=two to three times a week 4=once a week or less How would you rate your asthma control during the past 4 weeks? 1=not controlled at all 2=poorly controlled 3=somewhat controlled 4=well controlled 5=completely controlled Total Score: / 25
6 Chronic Urticaria (Hives) Quality of Life Questionnaire (CU-Q2oL) Patient name: Date: How much have you been troubled by the following symptoms? Minimum possible score is 1 (not at all), maximum possible score is 5 (very much). 1=Not at all 2=A little 3=Somewhat 4=A lot 5=Very much Circle Score Pruritus 1. Pruritus (itching) Wheals (welts, raised hives) Eyes swelling Lip swelling Impactties 5. Urticaria interferes with my work Urticaria interferes with my physical activities Urticaria interferes with my sleep Urticaria interferes with my spare time Urticaria interferes with my social relationships Urticaria interferes with my eating behaviour Do you have difficulties in falling asleep? Do you wake up during the night? Do you feel tired during the day because of your bad night sleep? Do you have difficulties in keeping concentration? Do you feel nervous? Do you feel in a bad mood? Do you have to put some limit in choosing your food? Does urticaria limit your sport activities? Are you troubled by drugs side effects? Are you embarrassed due to urticaria symptoms? Are you embarrassed in going to public places? Do you have any problems in using cosmetics? Do you have any limits in choosing clothes material? Total CU-Q2oL score
7 Allergy and Asthma Specialty Center General Consent for Care and Treatment TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risk and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides is with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating, that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at Allergy and Asthma Specialty Center. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions. I voluntarily request Dr. Rana Bonds to perform a reasonable and necessary medical examination, testing and treatment for the condition in which has brought me to seek care at this practice. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. Print Patient Name Signature of Patient/Personal Representative Date Relationship to Patient Signature of Witness Date
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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
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
New Patient Questionnaire
New Patient Questionnaire Welcome to Mass General/North Shore Cardiology. Please fill out the following questionnaire, answering each question to the best of your ability. The information will assist your
New Patient Registration
1 New Patient Registration Please Print New Patient Name (Last, First, Middle ) Nickname Maiden / Former Name Male / Female Single / Married / Divorced / Widowed Age Date of Birth Social Security Number
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
PATIENT INTAKE AND HISTORY FORM
PATIENT INTAKE AND HISTORY FORM (Please print) Name Date of Birth Race: American Indian or Native Alaskan Asian Black/African-American Native Hawaiian or Other Pacific Islander White Refused to report/unreported
1960 FP CENTER FOR SLEEP DISORDERS
1960 FP CENTER FOR SLEEP DISORDERS Sleep Questionnaire Name: Date: Date of Birth: / / Age: Gender: Height: Weight: lbs. Referring Physician: Occupation: Please give a brief description of your sleep problem
COMPREHENSIVE NEW PATIENT QUESTIONNAIRE
What brings you in today? What do you prefer to be called (nickname)? Please list all of your medical conditions. 1. 5. 2. 6. 3. 7. 4. 8. What surgical or medical procedures have you had in the past? 1.
Schodack Internal Medicine and Pediatrics. Annual Physical-Female
Schodack Internal Medicine and Pediatrics Annual Physical-Female Please Fill out this form (or have your caregiver complete it) and discuss with your medical provider. Thank you! Please Mark the preferred
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
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
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
SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:
Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression
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
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records