725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
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1 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 (770) (770) (facsimile) PATIENT QUESTIONNAIRE Referring Physician: Phone#: CURRENT PHYSICIANS Name Specialty MEDICATION LIST: (Including herbal, vitamins, etc.) MED Dose Directions Reason DRUG ALLERGIES: NON-DRUG ALLERGIES: PAST MEDICAL HISTORY: (Including previous hospitalizations with dates if possible, i.e., month/year, name of doctor who took care of you) PAST SURGICAL HISTORY: (Month/year, hospital name, name of the surgeon)
2 Page 2 of 6 OB/GYN HISTORY: First Menstrual Period Number of Pregnancies Last Normal Menstrual Period Number of Live Births Age at First Delivery Age at menopause Estrogen replacement therapy Years Cause of menopause Surgical / Natural - If surgical, do you still have ovaries? Y N Yrs. of Birth Control Pill Use SOCIAL HISTORY: Single Married Divorced Widowed Number of children Occupation Exposure to any toxic substance? If so, what? Tobacco use: Cigarettes pk/day, since age, quit at age Snuff Chew Alcohol use: No Yes - What amount? Frequency Illegal drugs FAMILY HISTORY: (Illnesses in your family such as diabetes, high blood pressure, etc.) Father: Mother: Siblings: Grandparents: Aunts/Uncles: S = Sister, B = Brother, P = Paternal, M = Maternal, GF = Grandfather, GM = Grandmother CANCER Any history of Cancer in your FAMILY: Breast ( ) Colon: ( ) Ovary: ( ) Other: ( ) Relation to you: diagnosis Alive Age Deceased
3 Page 3 of 6 REVIEW OF SYSTEMS: (Please mark those that apply) GENERAL: Since EYES: Since ( ) Fever ( ) Blurred Vision ( ) Chills ( ) Vision Changes ( ) Night Sweats ( ) Pain ( ) Weight Loss Amount ( ) Redness ( ) Weight Gain Amount ( ) Itching ( ) Fatigue ( ) Poor Appetite ( ) Pain ENT: Since: CARDIAC-PULMONARY Since: ( ) Bleeding Gums ( ) Chest Pain ( ) Nose Bleed ( ) Palpitations ( ) Sore Throat ( ) Orthopnea ( ) Hoarseness ( ) Shortness of Breath ( ) Earache ( ) Shortness of Breath With exertion ( ) Hearing Loss ( ) Swelling of feet/ankles ( ) Ringing in Ear ( ) Nasal Drainage ( ) Mouth Sores RESPIRATORY: Since: GI: Since: ( ) Cough ( ) Difficulty swallowing ( ) Shortness of breath ( ) Nausea ( ) Bloody Sputum ( ) Vomiting ( ) Wheezing ( ) Bloating ( ) Filling Full ( ) Heartburn ( ) Abdominal Pain ( ) Rectal Bleeding ( ) Black Stool ( ) Bloody Bowel Movement ( ) Constipation ( ) Diarrhea ( ) Bowel Incontinence ( ) Change in Bowel Habits ( ) Painful Bowel Movement
4 GU: Since: MUSCULOSKELETAL: Since: ( ) Urinary Tract Infection ( ) Stiffness ( ) Urgency/Frequency ( ) Muscle Cramps ( ) Urinary Incontinence ( ) Weakness ( ) Pain on Urination ( ) Arthritis ( ) Bloody Urine ( ) Muscle Pain ( ) Difficulty Urinating ( ) Bone Pain ( ) Burning with Urination ( ) Back Pain ( ) Pain during Urination ( ) Claudication ( ) Painful Menstrual Cycle ( ) Joint Pain ( ) Prostatism (Males) ( ) Muscle Pain Weak Stream ( ) Pain in leg after walking ( ) Recurrent Bladder Infections EXTREMITES: Since: BREAST: Since: ( ) Weakness ( ) Breast Mass ( ) Foot Drop ( ) Skin Changes ( ) Numbness of Hand ( ) Nipple Discharge ( ) Numbness of Feet ( ) Breast Pain ( ) Arm Swelling ( ) Leg Swelling ( ) Leg Pain SKIN: Since: NEUROLOGICAL: Since: ( ) Rash ( ) Weakness ( ) Itching ( ) Weakness in arms ( ) Pigmentation Changes and/or legs ( ) Difficulty Balance ( ) Tremors ( ) Headache ( ) Numbness ( ) Tingling ( ) Seizure ( ) Memory Loss PSYCHIATRIC: Since: ENDOCRINE: Since: ( ) Depression ( ) Heat or Cold Intolerance ( ) Anxiety ( ) Hot Flashes ( ) Mental Disturbance ( ) High or Low Sugar ( ) Sleep Disturbance ( ) Thyroid Nodules ( ) Hyper/Hypo thyroid ( ) Increase/Decrease In Libido ( ) Diabetes ( ) Increased Thirst Page 4 of 6
5 BLOOD: Since: ALLERGIC/IMMUNOLOGIC: Since? ( ) Abnormal Bruising ( ) Persistent Infections ( ) Bleeding ( ) HIV Exposure ( ) Enlarged Lymph Nodes ( ) Rash ( ) Clotting ( ) Anemia ( ) History of Blood Transfusion ( ) History of Marrow Transplant ( ) Leukemia Page 5 of 6 Other:
6 Page 6 of 6 FAMILY SUPPORT: Do you have family or friends who can support you during your illness such as being able to help you at home with daily living activities, bring you to office or hospital, bring you medications, call doctors, etc? No Yes Name: Relation: Distance from your home to our office? Religious Preference: PERSONS/ORGANIZATIONS Authorized to RECEIVE information: 1. Name : Phone: 2. Name : Phone: 3. Name : Phone: 4. Name : Phone: 5. Name : Phone: LIVING WILL: Do you have a Living Will? Yes No If yes please provide a copy to the nurse. If not, would you be willing to execute a living will? Yes No
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Placer Private Physicians: Patient Health Questionnaire [2]
![Placer Private Physicians: Patient Health Questionnaire [2]](/thumbs/87/96006031.jpg "Placer Private Physicians: Patient Health Questionnaire [2]")
Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
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
Osher Center for Integrative Medicine Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician:
Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician: How did you hear about us? What are your goals for this visit? Where would you like to see improvement in your child s health?
Patient Name Date of Birth Age. Other phone ( ) . Other
GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages
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-