Comprehensive Screening (adult)
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- Walter Goodwin
- 5 years ago
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1 Comprehensive Screening (adult) Patient Name: _ DOB: / / Today s Date: / / Which type of visit does your daughter need today? Address a specific symptom or issue Medication questions/refills (list meds) Illness or Physical Symptoms Social, Emotional, Mood Concerns Sexuality, Gynecology Nutrition, Body Image Risk Behaviors, Safety Other: Please Explain OR Annual Exam (well-check) which includes School / camp / college physical forms Annual disability paperwork Immunizations Wellness screening labs Brief update of chronic, stable conditions Refill of medications (no changes or problems) General health education If the physician conducts BOTH types of services, additional fees may be charged or a separate appointment may be needed. Additional FEES: Please understand that most insurance companies do not pay for care of problems and preventive care on the same day. The patient would be responsible for the additional fees. Additional TIME: There may not be enough time to thoroughly address everything. Another appointment may be needed to fully address all the issues. Your Name: Relationship to Patient: Mother Father Other: Signature: Date: / / Please give to the front desk staff: Immunization Records Forms (e.g. camp,sports) that require medical provider signature If new patient, who referred you to Girls to Women? Referred by: physician therapist Other:
2 Overall, how is she is doing Doing Well / No concerns Physical Health Symptoms School/ Work Minor Concerns Major/ Significant Concerns general level of motivation, work ethic, attendance, performance Relationships outside the home friends, teachers, co-worker Family Relationships parents, siblings and others at home Self-Care basic hygiene, bathing, sleeping Nutrition/ Body Image Sexual Health eating patterns, self-image Puberty, sexual development, sexual identity, birth control, sexually transmitted diseases, pregnancy Please describe Mood/ Attitude Risk Behavior general level of happiness, optimism, work ethic, hopefulness inappropriate internet and/or cell phone use; alcohol / marijuana / drug use; sneaking out; inappropriate sexual behaviors/relationships Safety Concerns self-harm, suicidal thoughts About your daughter Your relationship to Patient: Mother Father Other: What about her makes you proud? What seems to be the greatest challenge for her? % (out of 100) Overall Functional Assessment: Compared to what you think would be normal, healthy life functioning, how do YOU THINK you/your child is doing (no right or wrong answer, just your best guess)?
3 Current Medications Medication Name Dose Prescribing Physician Need Refill? Quantity Needed Medical History Prenatal / Birth History: Normal Issues/Concerns: Overall Growth and Development: Normal Issues/Concerns: Age of first period: or Have not started period Medication Allergies (and reaction) Food/Other Allergies (and reaction) Any surgeries (physician, approximate age or date) Any Hospitalizations (clinic/hospital/treatment center, approximate age or date) Most recent Annual (Wellness) exam: Most recent lab tests Approximate Age or Date: Physician: Cholesterol Approximate Age or Date: Results: Normal Abnormal Anemia Approximate Age or Date: Results: Normal Abnormal Other Approximate Age or Date: Results: Normal Abnormal Patient Social History School: Current Grade (e.g. 7 th ): School Year (e.g ) Activities, Clubs, Hobbies: Employment: Who does patient live with most of the time? Occupation Mother Father Step-Mother Step-Father Brother(s) Ages: Sister(s) Ages: Parents are: Married Separated Divorced ( Mom remarried Dad remarried) Widowed If patient lives in more than one home, what are the custodial arrangements?
4 Patient Medical Issues (Past or Present) Check this box if none apply Allergy/Asthma/Immunology asthma seasonal allergies food allergies frequent infections immune deficiency Dermatology acne eczema birthmarks Gastroenterology irritable bowel syndrome reflux,gerd, heartburn chronic constipation Crohn s or ulcerative colitis celiac disease gall bladder / liver disease blood in stools Endocrine thyroid disorder diabetes type 1 diabetes type 2 PCOS Orthopedic broken bones arthritis scoliosis joint probelms Infectious Disease chicken pox mononucleosis recurrent pneumonia recurrent sinus infections MRSA Age of Diagnosis Specialist Current Status (Please explain)
5 Patient Medical Issues (Past or Present) Check this box if none apply Cardiovascular/Hematology anemia (explain type) heart murmur abnormal heart valve(s) fainting or dizziness with exercise bleeding disorder blood clot / clotting disorder high cholesterol high blood pressure Neurology migraines tics seizures other Gynecology/Urology recurrent urinary tract infections kidney problems severe menstrual cramps irregular periods ovarian cyst(s) sexually transmitted infection pregnancy Neurodevelopmental birth complications developmental delay genetic disorder learning disorder autism Asperger s ADD/ADHD speech or language delay Psychological depression anxiety eating disorder alcohol use drug use tobacco use suicide attempt cutting / self-harm behavior Age of Diagnosis Specialist Current Status (Please explain)
6 Family MEDICAL History or Check this box if none apply Asthma Bleeding or clotting disorders Blood disorders or sickle cell anemia Heart attack/stroke High blood pressure High cholesterol Kidney disease PCOS Migraine headaches Obesity Diabetes Thyroid disease Crohns/ulcerative colitis Rheumatoid arthritis Cancer (type) ( ) Other Mother Father Siblings Grandparents Other Family MENTAL HEALTH History or Check this box if none apply Depression Anxiety OCD Bipolar Schizophrenia Learning disability ADD/ADHD Alcohol/drug abuse Eating disorder Suicide Other Mother Father Siblings Grandparents Other
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Vanessa Schulte, CCMA Practice Administrator Huntsville Hospital Pediatric Neurology
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Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form
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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
Adult Health History Summary
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Adult Health History for New Patient
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Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
Adult Health History
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Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
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GIDEON G. LEWIS, M.D.
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Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
CLIENT INTAKE FORM. Please describe your main reason(s) for seeking services at this time?
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Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?
Your Name: Date of Birth: Age: Address: City/State/Zip: _ Phone (home): (mobile): (work): Email: Shall we add you to our e-newsletter? Y / N Your Employer: Employer Phone: Employer Address: Your Occupation:
An affiliate of Saint Mary's Health System FRANKLIN MEDICAL GROUP, PC. NEW PATIENT INTAKE FORM. Last Name: First Name: DOB: Age:
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~ \ NSMI The National Sports Medicine InstJtute 19455 Deerfield Avenue Su ite 3 12 Lansdowne, Virgin ia 20 I76 24430 Stone Spring Blvd, Suite 250, Dulles, Virginia 20166 Patient Information: Last Name:
PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
PATIENT DATA SHEET GENERAL INFORMATION / / DATE LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY STATE ZIP CODE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS SEX MALE FEMALE (PLEASE CIRCLE)
Other doctors to receive copies of records : Chief complaint / history of present illness (Describe why you have been referred here):
Patient Name: Date: Age: Date of Birth: Preferred Name: Preferred Language: Address: City: State: Zip: Phone: Cell Phone: Preferred Phone: Emergency Contact: Relationship: Email: If you would like to opt
Demographic Information Form
Demographic Information Form PATIENT INFORMATION Male Female Other / / (Patient Legal Last Name) (Patient Legal First Name) (MI) (DOB) Mailing: SSN#: - - Home Cell Relationship Status (circle one): Single