Urology CHIEF COMPLAINT ALLERGIES. What is the main reason for your visit today? Allergen Yes No Reaction
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1 Urlgy Kari White, NP Phne: Name: Date f Birth: Date: CHIEF COMPLAINT What is the main reasn fr yur visit tday? ALLERGIES Are yu allergic t any f the fllwing? Please check YES r NO fr each. Check here if yu have NO knwn allergies. Allergen Yes N Reactin Penicillin Sulfa Latex IV Cntrast Dye Cipr/Levaquin Macrbid/Nitrfurantin Others (please list) 1
2 Urlgy MEDICATIONS Please list the name, dsage and frequency f all medicatins yu are taking (include regularly used ver-the-cunter medicatins/supplements). IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM. Check here if yu are currently taking NO medicatins. Medicatin Dse Hw Often? SURGICAL HISTORY Have yu ever had any f the fllwing surgeries r prcedures? Please check YES r NO fr each. Check here if yu have had NO surgeries r prcedures. Urlgic Surgeries Yes N Date Kidney surgery Bladder r Incntinence surgery Males Only Scrtal/Testicle surgery Penis surgery Gyneclgical Surgeries (Females nly) Yes N Date Hysterectmy C-Sectin (Number f deliveries: ) 2
3 Abdminal Surgeries Yes N Date Appendix remval Gallbladder remval (chlecystectmy) Hernia surgery Grin (inguinal)? Side? Navel (umbilical)? Remval f bwel Bag fr drainage f stl (stmy)? Aneurysm repair Brain, Head r Neck Surgeries Yes N Date Cartid surgery Chest Surgeries Yes N Date Heart bypass Artificial heart valve Jint r Bne Surgeries Yes N Date Artificial jint/replacement? Which ne? Orthpedic prcedures? Other Surgeries (Please List) Date 3
4 PAST MEDICAL HISTORY Have yu ever been treated fr any f the fllwing medical prblems? Please check YES r NO fr each. Cnditin Yes N Adrenal Prblems Asthma/Emphysema Bld Clts/Bleeding Prblems/Deep Vein Thrmbsis/Pulmnary Emblus Cancers (please list): Cataracts Cngestive Heart Failure Diabetes Gastrintestinal Bleeding Glaucma Gut Heart Attack/Strke Hepatitis High Bld Pressure HIV/AIDS Irregular Heart Beat Kidney Failure Kidney Stnes Mumps Sleep Apnea Thyrid Disease Tuberculsis Urinary Infectins Females Only: Number f Pregnancies: Number f Miscarriages: Other (please list): FAMILY HISTORY D yu have any clse relatives with any f the fllwing cnditins r d any f the fllwing cnditins run in yur family? Please check YES r NO fr each. Cnditin Yes N Prstate Cancer Bladder Cancer Kidney Cancer Kidney Stnes Diabetes High Bld Pressure Other Cancers Other (please list): 4
5 SOCIAL HISTORY Please check r fill in the apprpriate answer fr each questin. Questin Answer What is yur marital status? Married Single Divrced Separated D yu smke? Yes, Daily Yes, Nt Daily Nt Anymre Never Smked Cigar Cigarettes If yes, what d yu smke? Vaprizer Marijuana Hw lng have yu smked? When did yu quit? Hw many packs per day? D yu use any f the fllwing: Chewing tbacc/snuff Edible marijuana Illegal substances (drugs) D yu drink alchl? Yes N Nt anymre Hw much d yu drink per week? What d yu drink? Beer Wine Liqur When did yu quit? Hw many caffeinated beverages d yu have per day? Have yu ever had a bld transfusin? What is yur primary language? English Japanese German French Chinese Russian Spanish Italian Prtuguese Other: What is yur race? White Other: Hispanic/Latin Asian American Indian/Alaskan Native Native Hawaiian /Pacific Islander Black/African American What d yu d fr a living (what is yur ccupatin)? 5
6 REVIEW OF SYSTEMS Check here if yu have n prblems in any areas Cnstitutinal Yes N Fever Chills Weight Lss Eyes Yes N Blurry Visin Duble Visin Cataracts Ears, Nse, Muth, Thrat Yes N Hearing Lss Nasal Stuffiness Sre Thrat Cardivascular Yes N Chest Pain Swllen Ankles Irregular Heart Beat Pacemaker Internal Defibrillatr Crnary Stents Angicaths Respiratry Yes N Shrtness f Breath Wheezing Chrnic Cugh Gastrintestinal Yes N Abdminal Pain Nausea/Vmiting Cnstipatin Diarrhea Musculskeletal Yes N Chrnic Back Pain Chrnic Neck Pain Sre Muscles Integumentary, Skin Yes N Rash Persistent Itchiness Skin Cancer Histry Neurlgical Yes N Numbness Dizziness Tingling Hematlgical, Lymphatic Yes N Swllen Glands Abnrmal Bleeding Bruise Easily Endcrine Yes N Chrnic Fatigue Chrnically t Ht/Cld Excessive Thirst Respiratry Yes N Shrtness f Breath Wheezing Chrnic Cugh Sexual Functin Yes N Sexually Active Decreased Erectins Ejaculatin Issues Decreased Libid Other: I have read and answered all f the questins in their entirety and the infrmatin is accurate and true t the best f my knwledge. Signature Date 6 6
IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM.
Dr. Doug Scherr Date of Birth: Date: CHIEF COMPLAINT What is the main reason for your visit today? ALLERGIES Are you allergic to any of the following? Please check YES or NO for each. Check here if you
New Patient Registration and Medical History. Address City State Zip code
Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719 2441 / Fax (724)719 2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
New Patient Registration and Medical History. Address City State Zip code
Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
PATIENT INFORMATION. Last Name: First Name: Address: City/State/Zip: Phone: (H): (W): (C): Date of Birth: Gender: Male Female
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Patient Health History
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Patient Information Packet Date:
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ALVIN & LOIS LAPIDUS CANCER INSTITUTE HEMATOLOGY / ONCOLOGY PATIENT HEALTH HISTORY Name: Date of Birth: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Social Security Number: Your Primary
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
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
454-8 (Insert) MEDICATION GUIDE ZUBSOLV (Zub-solve) (buprenorphine and naloxone) Sublingual Tablet (CIII) IMPORTANT: Keep ZUBSOLV in a secure place
MEDICATION GUIDE ZUBSOLV (Zub-slve) (buprenrphine and nalxne) Sublingual Tablet (CIII) IMPORTANT: Keep ZUBSOLV in a secure place away frm children. Accidental use by a child is a medical emergency and
PATIENT INTAKE AND HISTORY FORM
PATIENT INTAKE AND HISTORY FORM (Please print) Name Date of Birth Race: American Indian or Native Alaskan Asian Black/African-American Native Hawaiian or Other Pacific Islander White Refused to report/unreported
Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Occupation Employer
Milham Family Chirpractic Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex M F Marital Status M S D W Date f Birth Age Occupatin Emplyer Referred by: Have yu ever received Chirpractic
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female
Place Patient Sticker Here Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female Social Security # Marital Status: Single Married Divorced Widowed Ethnicity: Non Hispanic
BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM
PATIENT MEDICAL HISTORY FORM Name: Date: Social Security #: DOB: Height: Weight: Email: Primary Care Physician: Referred by: Pharmacy Name/Location/Phone Number: Dialysis Center and Phone Number (if applicable):