Do not take any antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hrs
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- Stanley O’Brien’
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1 HEALTH QUESTIONNAIRE Do not take any antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hrs Patient s Name: Date of Birth: Date of Appointment: INSTRUCTIONS: Please answer the questions as they relate to the person being evaluated. A complete, accurate record is important in learning about your problems. Bring this completed form with you to your first appointment. Briefly describe your symptoms, the reason for your visit, and what you hope to accomplish: PROBLEMS: Have you ever had the following conditions? Yes No Check all items Age at Severity Comments- What Onset onset Mild Mod Severe medications helped? Asthma - wheezing Breathing problems-shortness of breath/cough Sinus trouble Hay fever- runny/stuffy/itchy nose/sneezing Hives/swelling Abdominal pain/heartburn/frequent burping Eczema/other rashes Recurrent/frequent infections- sinus/ear Reactions to foods Reactions to drugs Reactions to insect stings Reactions to latex SYMPTOMS: Have you ever had any of the following? If not, leave blank. Runny/stuffy nose Itchy nose Sneezing Sinus pressure/headaches Ears- popping/fluid/pain/infection Eyes- red/watery/itchy Wheezing Throat- clearing/postnasal drip Coughing Wheezing/coughing with exercise Skin problems How many Severity Circle the most severe months days last month? Mild Mod Severe PatientForms>HealthQuestionnaire 04/13mm Page of 6
2 4. MEDICATIONS: List all medications you are taking now by name, dosage, number of times per day. Include prescriptions, over the counter, oral medications, nasal sprays, eye drops, and all vitamins and supplements. Name of medication Dosage Times per day Present medication for allergies Medications taken in the PAST for allergies Present medications for other reasons Drug allergies- list drug and reaction 5. PREVIOUS ALLERGY EVALUATION AND THERAPY Have you ever had allergy skin tests? YES NO If YES - When? Allergy blood test? YES NO If YES - When? Physician: Please list the results of testing: (If possible, please provide copies) Have you ever received allergy injections? YES NO If YES- When? 6. PRECIPITATING FACTORS (TRIGGERS) Check each symptom box which applies when you are exposed to the following. Asthma Nose/Ears Eyes/Throat Headache Eczema Hives Other A. Environmental Dust exposure- sweeping/vacuuming Molds- mildewed areas/raking leaves Animal dander 4. Outdoor pollens- grass/trees/weeds B. Weather/environmental changes High winds Humidity Cold dry air 4. Air conditioning/heating C. Respiratory infections/colds D. Physical exertion E. Irritants- tobacco smoke/strong odors/cleaning /chemicals F. Pollutants- smog/motor fumes/sulfur dioxide/ nitrous oxide G. Foods- food additives/colorings/preservatives H. Emotional expressions- laughter/crying I. Stress J. Hormone factors- menses/other K. Medications Aspirin or NSAIDs Other L. Other triggers not listed PatientForms>HealthQuestionnaire 04/13mm Page of 6
3 7. REVIEW OF SYSTEMS: Circle each word which applies in each category. PART A: PERTINENT TO PRESENT PROBLEMS/EXTENDED CATEGORY General Health Excellent Good Fair Poor Full Body Fever Chills Fatigue Weakness Night sweats Head Headache Trauma Sinus pressure Eyes Itchy Tearing Swelling Discharge Redness Cataracts Glaucoma Vision problems Pain Ears Infection Pain Hearing problems Discharge Tinnitus Vertigo Ventilation tubes Myringotomy Nose Obstruction Drainage Post nasal drip Bleeding Dryness Frequent colds Good sense of smell Problems with smell Sinus infections Sneezing Itchy Polyps Snore Adenoidectomy Mouth Throat Skin Palate itching Changes in taste Mouth sores Sore throats Throat clearing Post nasal drip Hoarseness Tonsillitis &A age: Itching Dryness Hair/nail changes Rashes Hives Eczema Swelling Seborrhea Infections Pulmonary Chronic cough: Day Night Sputum (phlegm) Wheeze Shortness of breath Chest tightness Pain Hemoptysis Chronic/Recurrent infections Colds Sinuses Ears Bronchitis Pneumonia Diarrhea PART B: COMPLETE REVIEW OF SYSTEMS Recent weight loss Number of pounds over months or years Cardiovascular Palpitations Shortness of breath Pain Swelling Blood Pressure: HIGH LOW Arrhythmias Genital/Urinary Burning Pain Frequency Large amounts of urine Blood in urine Endocrine (hormonal) Thyroid Diabetes Cushings Blood Anemia Transfusions Lymph node enlargement HIV Testing: Bones/Joints/Muscles Pain Swelling Deformity Neurologic Syncope Seizures/convulsions Gait problems Coordination problems Paralysis Weakness Speech problems Gastrointestinal Nausea Vomiting Diarrhea Constipation Gas Regurgitation Pain Colored stool: Black Tan Green Blood in stool Ulcers 8. PAST MEDICAL EVALUATIONS - DIAGNOSES - LAB WORK - X-RAYS: Please provide any information available with type of test, when and where performed. Type of testing Date of testing Where was this testing done PatientForms>HealthQuestionnaire 04/13mm Page of 6
4 9. PAST MEDICAL HISTORY A. Please list other illnesses or chronic medical conditions you have had. B. List all hospitalizations/surgeries: Please list most recent first with reason and date. 4. C. Immunizations: Did you experience any significant allergic reaction to any administered vaccine? If YES, please note what type of reaction to which vaccine in the space provided below. Are your immunizations up to date? YES NO Date of last TETANUS: Date of last TB PPD TEST: Indicate here any reaction to vaccines you have experienced. Date of last Pneumovax: Date of last Shingles: 10. FAMILY HISTORY: Do any members of your family have allergies? Asthma Hay Fever Eczema Hives Frequent pneumonia, sinus/ear infections Headaches Other allergies Medication allergies Hymenoptera- Wasps/bees/ant/etc. Do any members of your family have any other illnesses? Emphysema/other lung Diseases/Tuberculosis Cystic fibrosis Cardio-vascular disease Thyroid disease Glaucoma Diabetes Other YES NO If YES, list all relatives (parent/grandparent/sibling/children/etc.) YES NO If YES, list all relatives as described above. PatientForms>HealthQuestionnaire 04/13mm Page of 6
5 1 ENVIRONMENTAL SURVEY Where do you live? Age of your house? House construction: Type of heating: Forced air Steam City Rural years months (brick, wood, etc.) Space heater Baseboard Other: Type of air conditioning: Central Window Do you have an: a. Air purifier? Central Window unit b. Humidifier? Central Window unit Are any rooms damp or musty? YES NO If yes, which ones? How many indoor plants do you have in the house? Type of Carpet: Wool Synthetic Jute Other: Wall to Wall: YES NO Is entire house carpeted? YES NO Please list all rooms where carpeting is located: Do you have any stuffed furniture/soft upholstered/pillows? YES NO Which: Do you have any feather comforters? YES NO Do you have DOWN jackets/clothing? YES NO Is your mattress: Foam rubber Innerspring/cotton Cotton Waterbed Other: How old is your mattress? years months Is it encased in plastic: YES NO What kind of grasses, shrubs, trees, and weeds grow in the immediate vicinity of your home? Do you have any pets? If YES, list number and kind (dog, cat, bird, horse, etc.): Do your pets spend time INDOORS? YES NO Are they allowed in the bedroom? YES NO 1 SOCIAL/OCCUPATIONAL/EDUCATIONAL HISTORY A. RESIDENCE: List your past residencies (city, state) with most recent first. City, State Urban or rural # of years Effect on Symptoms (Better, worse, no change) B. OCCUPATIONAL HISTORY: list present occupation first, then past occupations. Brief job description How long? Effect of workplace on symptoms Are you exposed to anything at work which might aggravate your condition? If YES, what are they? Have you missed any work or school due to your allergies and/or asthma? If YES, how much time in the past 12 months? PatientForms>HealthQuestionnaire 04/13mm Page of 6
6 C. HOBBIES/RECREATIONAL ACTIVITIES: Please list any other exposures from these activities. 4. D. DO YOU TRAVEL FREQUENTLY YES NO Are your symptoms better/worse at certain locations? Please describe. E. EDUCATION: Please indicate highest grade completed. Grade school High school College Other: F. MARITAL STATUS: Single Married Separated Widowed Number of children: G. SEXUAL BEHAVIOR: Heterosexual Bisexual Homosexual NONE H. TOBACCO SMOKING HISTORY: Do you presently smoke? YES NO If YES, how many years have you been smoking? years Have you ever smoked? YES NO If YES, when did you stop? Average cigarettes per day at highest point: If you still smoke, do you think you could stop? YES NO Do any family members living with you now smoke? YES NO If yes, which ones? I. DO YOU NOW OR HAVE YOU EVER USED RECREATIONAL DRUGS? YES NO If YES, were they: Oral Nasal IV 1 PSYCHOLOGICAL PROFILE: Please circle all the words you would use to describe yourself (or your child.) Timid Unfriendly Well adjusted Concerned Anxious Independent Quiet Introvert Few friends Depressed Many friends Manipulative Aggressive Tense Spoiled Bustling Shy Extrovert Forward Calm Dependent Happy Relaxed Usually ill Do you feel that psychological issues may play a role in your (or your child's) allergy problem? YES NO If so, how? Please provide any additional information which you feel might help us in evaluating the problem. PatientForms>HealthQuestionnaire 04/13mm Page of 6
HEALTH QUESTIONNAIRE. Do not take antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hours
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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
New Sleep Patient Questionnaire. Name Age Date. General Medical History 1. Please list any surgeries you have had and their approximate dates:
1 John S. Kim, M.D., Diplomate ABSM Lawrence A. Lynn, D.O., FCCP 1251Dublin Rd. Columbus, Ohio 43215 (614) 297-7704 (614) 297-7705 New Sleep Patient Questionnaire Name _ Age Date General Medical History
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
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
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
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
(pedi) Patient Name: date of birth:
(pedi) Patient Name: date of birth:_ Date: I am being seen on: a) self referral _ b) physician referral from Dr. Please share the main reasons for your office visit today (check all those that apply):
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:
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:
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
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
NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name
NEW PATIENT FORM Please print in ink and fill in all blanks Please fill out front and back Patient s Full Name Date of Birth Age Sex Social Security Number Referring Doctor or Family Physician Phone #
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
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
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
Broward Oncology Associates, P.A. PATIENT INFORMATION
NAME: BIRTHDATE: AGE: LOCAL ADDRESS (Street city state zip): HOME TELEPHONE# CELL # SOCIAL SECURITY #: - - SEX MARITAL STATUS WHAT IS YOUR HT? WHAT IS YOUR WT? EMPLOYER WORK# SPOUSE'S NAME SPOUSE'S EMPLOYER
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
Safety Precaution Tips Against Seasonal Allergies (Hay Fever) By: Dr. Niru Prasad, M.D., F.A.A.P., F.A.C.E.P. WHAT IS HAY FEVER?
Safety Precaution Tips Against Seasonal Allergies (Hay Fever) By: Dr. Niru Prasad, M.D., F.A.A.P., F.A.C.E.P. WHAT IS HAY FEVER? Hay Fever is the most common type of seasonal allergies experienced by the
ENT & Allergy Specialists of VA Registration Form
ENT & Allergy Specialists of VA Registration Form Which provider are you seeing today? Dr. James J. Lee Dr. Vickie K. Lee Dr. Rachel Watson Please Print Clearly Last Name PATIENT PERSONAL INFORMATION (please
Patient Intake Form for Acupuncture Treatment at Infinite Healing
Section A: Your Information Patient Intake Form for Acupuncture Treatment at Infinite Healing Last Name: First Name: Middle Initial: Mailing Address: _ City: Postal Code: E-mail: Birth date: M D YR Age:
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other