PATIENT INFORMATION. Last Name First Name Address Zip Code City State
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1 ADVANCED ALLERGY & ASTHMA, PLLC Ellen Epstein, M.D. FAAAAI, FACAAI Adult and Pediatric Allergy 165 North Village Avenue Suite 141 Diplomate American Board of Allergy and Immunology Rockville Centre New York Tel: (516) PATIENT INFORMATION Last Name First Name Address Zip Code City State Phone: Home ( ) Work ( ) Cell ( ) Texting: Yes No Marital Status: Single Married Divorced Widowed Date of Birth / / SS# - - Spouse s Name Spouse s Phone Number ( ) Referred by Address Phone ( ) Ethnicity ANSWER BOTH QUESTIONS Nos. 1 and 2: 1. Hispanic/Latino Not Hispanic/Latino 2. American Indian/Alaska Native Asian White Other Black/African American Native Hawaiian/Pacific Islander If Child, Responsible Party: Name D/O/B / / Address Zip Code City State Phone: Home ( ) Work ( ) Cell ( ) SS# - - D/O/B / / Patient Employed by Phone ( ) Address of Employer Primary Care Physician Phone ( ) Pharmacy Name Pharmacy Phone ( ) Person to Contact in Emergency: Name Address Relationship Phone: Home ( ) Cell ( )
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3 Ellen Epstein, M.D. FAAAAI, FACAAI Adult and Pediatric Allergy 165 North Village Avenue Suite 141 Diplomate American Board of Allergy and Immunology Rockville Centre New York Tel: (516) Fax (516) PATIENT AGE DATE COUNTRY OF BIRTH RACE SEX M F MARTIAL STATUS Single Married Divorced Widow REFERRED BY HISTORY OF: PERSONAL (WHEN DID THIS OCCUR?) FAMILY (SPECIFY MEMBER) Allergies REACTION: Atopic dermatitis/eczema Hives Itchy water eyes Sinus Infection Headaches (Frequent or Severe) Asthma Nasal congestion Chest symptoms Heartburn/reflux Difficulty swallowing Drug Allergy (circle if allergic) Penicillin Aspirin Sulfa X-ray Dye Local anesthetic Non steroidal antiinflammatory Other: Food Allergy, Mahi Mahi Trout/Tuna/Aged cheese List foods: Sulfite/red wine Chianti Insect Allergy Ever stung? List insect: Latex (rubber): Condom gloves balloons Abdominal Bleeding Anemia Anxiety Page 1 of 4
4 PATIENT AGE DATE 2 HISTORY OF: PERSONAL (WHEN DID THIS OCCUR?) FAMILY (SPECIFY MEMBER) Arthritis Back Disorders Backache Black Tarry Stools Bleeding Diseases Blood in Stool Cancer Cataracts Change in Bowel Habits Chest Pain Colitis Constipation (recent or persistent) Convulsion Cough (recent or persistent) Coughing Blood Depression Diabetes Diarrhea (recent or persistent) Difficulty Swallowing Dizziness Double Vision Enlarged Heart Emphysema Epilepsy Eye Problems Frequent Nighttime Urination Fainting Spells Gallstones Gall Bladder Disorder Glaucoma Heart Disease Heart Murmur Hepatitis High Blood Pressure Hoarseness of voice HIV or Exposure Treatment for HIV
5 PATIENT AGE DATE 3 HISTORY OF: PERSONAL (WHEN DID THIS OCCUR?) FAMILY (SPECIFY MEMBER) Indigestion Irregular Heartbeat Kidney Infection Kidney Stone Leg Pain Lung Disease Lyme Disease Nosebleeds Nervous Disorder Painful Urination Paralysis Phlebitis ( blood clots) Pleurisy ( lung problems) Pneumonia Pus in Urine Rash Rheumatic Fever Runny Nose Shortness of Breath Stroke Swelling of Feet Swollen/Painful Joints T.B. Thyroid Disease Ulcer Venereal Disease Personal and Social History Number of children Sexual Orientation Healthy? Medical Problems: Alcohol How much: times/day social Other Risk Factors Occupational/Recreational Recent Hospitalization Smoking NEVER ACTIVE # PACKS PER DAY # of YEARS PRIOR WHEN STOPPED Weekly Exercise Weight Variance This Year
6 PATIENT AGE DATE 4 Vaccine Status Hepatitis B Vaccine How many Chicken Pox (Varicella) How many HIV Status Date tested Results Occupation: Patient Spouse Patient: Spouse: Hobbies: Mammogram Date of last: Results: Normal Abnormal Pap Smear Date of last Results: Normal Abnormal Chest X-ray Date of last Results Normal Abnormal Last Menses Date: Normal Abnormal Pregnant Immunizations: Recent Hospitalizations Due Date: Flu shot Date Pneumonia shot Date List all Present Medications including over the counter and vitamins ENVIRONMENTAL HISTORY House years old Apartment: years old Length of occupancy years Is it near factories barns bakeries swamp water Flooring: carpeting bedroom living area basement HEATING SYSTEM: Baseboard Forced Air Radiator A/C Room Central None Fans: ceiling window Humidifier: none room central Basement: dry damp musty Dehumidifier: none room central Smokers at home: yes no where do they smoke? Feather pillow: yes no Pets: cat dog bird rodent other Completed by: Date: First Name Last Name Relationship to Patient: Self Other Reviewed by: Date: Signature Ellen Epstein, M.D. HISTORY UPDATED 11/17/2013
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
MEDICAL DATA SHEET For Patients 18 years of age and older
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WELCOME TO OUR OFFICE
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New Patient Information
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Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification
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PATIENT INFORMATION FORM (WOMEN ONLY)
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MEDICAL DATA SHEET For Patients 18 years of age and older
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Modesto Gastroenterology Medical Corporation
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3400-C Old Milton Parkway, Suite 425 1505 Northside Forsyth Drive, Suite 3400 Alpharetta, GA 30005 Cumming, GA 30042 Phone: 770-343-8760 Fax: 770-664-2101 Welcome to our practice! On behalf of North Point
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REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL NAME: BIRTH DATE: AGE: SEX: M F OCCUPATION: RACE: WHO REFERRED YOU TO OUR OFFICE? _ WHAT IS YOUR MAIN COMPLAINT? HOW LONG HAS THIS BEEN A PROBLEM? IS
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
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
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
PUGET SOUND ALLERGY, ASTHMA & IMMUNOLOGY
PUGET SOUND ALLERGY, ASTHMA & IMMUNOLOGY New Patient Questionnaire. Please answer all the questions as completely as possible. We appreciate your effort in helping us obtain current and complete information
Adult Health History New Patient
Adult Health History New Patient Today s Date PREFERRED NAME DATE OF BIRTH Reason for visit: What are your health goals for the next year? Previous Primary care Provider? Last visit? Specialists (Past
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?
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