WELCOME TO OUR OFFICE

Transcription

1 WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment Employer Address: City, State, Zip: Work Phone:( ) Referred By: In Case of emergency, contact: Relationship: Home Phone:( ) Work Phone:( )

2 PATIENT HEALTH HISTORY FORM Patient Name: Date of Birth Gender: Male Female: Preferred Language Marital Status: Single Married Divorced Widowed Race: American Indian/ Alaska Native Asian Black/African American Native Hawaiian or Other Pacific Islander White/ Caucasian Other Ethnicity: Hispanic or Latino Not Hispanic or Latino Do you have children Yes No How many? Do you live alone? Who lives with you Smoker: Current every day smoker Current some days smoker Former smoker Never smoked Do you drink alcohol? No, Never No, but I use to Rarely Yes Daily 1 or more time per week 1 or more times per month Are you at risk for HIV/AIDS (e.g. unprotected sex, drug use, previous blood transfusion)? No Yes (the physician will discuss with you during visit.) Have you ever had problems with anesthia? Yes No Past Medical History Please list any major illness and/or injuries. Surgeries/ Hospitalizations Year Complications

3 Patient Name: Date of Birth: Current Medications Allergies to medications? Allergies Family History Family Member Alive Deceased Age Health status or Cause of Death Grandmother(maternal) A D Grandmother(Paternal) A D Grandfather(maternal) A D Grandfather(paternal) A D Mother A D Father A D Sister/Brother A D Sister/Brother A D Sister/Brother A D

4 Patient Name: Date of Birth Review of Systems Are you currently having, or have had problems with: Constitutional Circle One Eyes Fever Weight Loss Excessive Fatigue Night Sweats Wear Glasses Infections Glaucoma Cataracts Ear, Nose, Throat and Mouth Wear Hearing Aids Hearing Loss Ear Pain Ear Infections Ringing in Ear(s) Balance Disturbance Nosebleeds Nasal Congestion Nasal Drainage Inability to Smell Sinus Problems Sore Throats Mouth Sores Cardiovascular/ Vascular Chest Pain or Angina High Blood Pressure Irregular Pulse Heart Mumur Date of Last Exam Circle: Left Right or Both

5 High Cholesterol Swelling in Feet or Hands Respiratory Asthma Chronic Cough Emphysema Shortness of Breath Bronchitis Pneumonia Lung Cancer Bloody Sputum Date of last Chest X ray Gastrointestinal Indigestion or Pain With Eating Nausea Vomiting Blood In your Vomit Liver Disease Jaundice Abdominal Pain Change in Bowel Habits Ulcers or Gastritis Colon Cancer Genitourinary Urinary Tract Infections Painful Urination Blood in your Urine Difficulty Starting or Stopping Stream Incontinence Kidney Stones

6 Prostate Cancer (males) Endometriosis(females) Uterine or Cervical Cancer Musculoskeletal Broken Bones Arm or Leg Weakness Back Pain Arm or Leg Pain Joint Pain or Swelling Arthritis Integumentary Skin Disease Skin Cancer Breast pain, Tenderness or Swelling Nipple Discharge(females) Date and Result of Last Mammogram Neurological Fainting Spells Seizures Problems w/ memory Disorientation Difficulty with speech Inability to concentrate Double or Blurred vision Face Weakness Coordination in Arm/ Legs Psychiatric Anxiety Depression Other Psychiatric Disorder/ Treatment

7 Endocrine Diabetes Thyroid Disease Increased Appetite Excessive Thirst or Urination Hormone Problems Hematologic/Lymphatic Anemia Hemophia Bleeding Tendencies Persistent Swollen Glands or Lymph Nodes Blood Transfusion If yes, when? Allergic/Immunology Food Allergies Inhalant (nasal) Immunologic Disorders Allergies The above information is accurate to the best of my knowledge. Patient Signature Date: I have reviewed the above information with the patient Physician name (Signature) Date: Physician Name:

8 ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES Medical Center Radiologists Inc. Must make a good faith effort to obtain an individual s written acknowledgement that he/she received the Notice of Privacy Practices. Acknowledging receipt of the Notice of Privacy Practices with you signature does not imply agreement or disagreement with this policy, just receipt of said policy. Signature Date: