Richard Senysyzn, MD Psychiatry for Adults 1260 River Acres Drive New Braunfels, TX , Fax. (888)
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- Eugene Wilkerson
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1 ADHD Evaluation Intake Form Patient Contact Information Patient Name: Date of Birth: Age: Last First MI Address: address: Contact phone number: Emergency Contact/Number/Relationship: Pharmacy: Primary Care Physician: Tel: Reason For Your Visit: What are your specific goals for ADHD Treatment (improve/fix what) HPI (doctor to compete this section): Hyperactivity (Fidget/restless/motion/loud/drive/talk/speak/waiting/intrude): Inattention (details/attn./listen/finish/org/delay/lose/forget/distract): Family: School/Work: Childhood: Legal/discipline: 1
2 Patient to Complete From Here to the end Drug Use History : Do You Smoke or Use Tobacco Products? When was your last alcoholic drink? In the past 30 days, about how many of those days have you had at least one alcoholic drink? What is the maximum number of drinks you have had in one day in the past month? DUI DWI Public Intoxication Seizures DT s Rehab Please check the appropriate boxes that apply to you for the following substances: Never Used Age first used Age it became a problem Age and peak use amount Lase use Current use and frequency Alcohol Amphetamine/Stimulants Marijuana/spice/synthetic Marijuana Cocaine Hallucinogens (LSD,mushrooms, Mescaline) Benzodiazepines (xanax, valium, ativan Restoril, Librium) Club Drugs Inhalants-gas/glue Bath Salts Ecstasy PCP or Angel Dust IV Drug use GHB Other: 2
3 Previous Treatment Please list any inpatient mental health hospitalization Hospital name/dates/reason _ Previous Outpatient Psychiatric History: Have you ever been treated for any of the following by either a family doctor or psychiatrist (check all that apply), if so, please list medications given: Depression ADHD Bipolar (Manic / Depressive) Disorder Anxiety OCD Schizophrenia Panic Attacks PTSD Alcohol Problems (including AA) Anorexia/ Bulimia Binge-eating Drug Problems ECT treatment Current and Previous MEDICAL Problems (Check all that apply High Blood Pressure Diabetes Heart Attacks Strokes Hepatitis Asthma Thyroid Sleep Apnea COPD Seizures Sexual Disease Heart Failure Hepatitis HIV Fibromyalgia Hysterectomy Tubal Ligation Migraines Urinary Cancer Bleeding Problems GI Problems Head Injury Kidney Cholesterol Last menstrual period (if applicable) Contraceptive method: List all prior surgeries and hospitalizations for MEDICAL illnesses Please List all current medications below (include birth control pills, over the counter medication and herbal remedies (i.e. decongestants, St. John s Wort etc) Allergies (Medication/Food): _ Family History: Has anyone in your family ever been treated for any of the following (please check all that apply and when appropriate indicate paternal or maternal) 3
4 Father Mother Aunt Uncle Brother Sister Children Grandparent Depression Anxiety Panic Attacks Post-traumatic stress Bipolar/Manic depression Schizophrenia Alcohol Problems Drug problems ADHD Suicide attempts Psychiatric hospital stay What MEDICAL Problems run on one or both sides of the family? (Diabetes, High Blood Pressure, etc) Social History: -Where were you born and raised? -Who raised you; your home life growing up? -How many siblings and what was your family like growing up? -Highest level of education -Marital status? -Your current living situation -Anyone in the home using drugs/alcohol? -Employment/length or employment? -Do you receive disability? -An history of physical or sexual abuse? -Who is your main emotional support? -Plans over the next year? -Have you ever been in jail or prison other than earlier noted? 4
5 Review of Systems: (please circle all that apply) General: Recent weight loss, recent weight gain, weakness, fatigue, night sweats, fevers Eyes: Double vision, blurred vision Ears, nose, throat: Dry mouth, hoarseness, difficulty swallowing Respiratory: Cough, sputum, shortness of breath at rest, shortness of breath with activity Cardiovascular: Heart trouble, chest pain or discomfort, palpitations Gastrointestinal: Ulcer, trouble swallowing, heartburn, change in appetite, nausea, diarrhea, constipation, rectal bleeding Urinary: Increased frequency of urination, incontinence, problems with urination Musculoskeletal: Muscle or joint pain or stiffness, joint pain, redness, swelling Psychiatric: Anxiety, depression, mood unstable, suicidal thoughts Neurologic: Headaches, dizziness, vertigo, fainting, blackouts, seizures, weakness, numbness or loss of sensation, tremors or other involuntary movements, seizures MSE/Impression: See face sheet Patient Signature Date: 5
Psychiatric Evaluation Intake Form
Patient Contact Information Psychiatric Evaluation Intake Form Patient Name: Date of Birth: Age: Last First MI Address: Contact phone number: Email address: Emergency Contact/Number/Relationship: Primary
Psychiatric Evaluation Intake Form
Psychiatric Evaluation Intake Form Patient Contact Information Patient Name: Date of Birth: Age: Last First MI Address: Contact phone number: Email address: Emergency Contact/Number/Relationship: Primary
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
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Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
HD CLINIC MEDICAL HISTORY FORM
HD CLINIC MEDICAL HISTORY FORM Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the questions below as best as you can. If you need assistance, a caregiver/companion
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
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
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
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
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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:
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5
Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact#: Alternate#: Work#: Date of Birth: / / Sex: Male Female SS# (optional): Marital Status : Single Married Divorced
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
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Gender: M F Race: Caucasian African American Hispanic Other
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725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
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The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION Name: Email: Daytime Phone Number: Date of Birth: / / Age: How did you hear
Initial Patient Intake Form
Initial Patient Intake Form Patient Registration Today s Date Patient Name (last) (first) (middle) Address (city) (state) (zip) Date of birth (mm/dd/yyyy) SSN # Current Gender Identity: Male Female Transgender
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DNA CENTER New Patient Information
DNA CENTER New Patient Information Name Email: Address City State Zip Home Phone Work Cell Phone Social Security Number Date of birth Gender ( Male/Female) Age Please Circle: Hispanic/Latin or Non Hispanic/Latin