Steven J. Smith Kingwood Dr., BLDG. 6 Kingwood, Texas 77339
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- Alexander McDowell
- 5 years ago
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1 97 Kingwood Dr., BLDG. 6 Kingwood, Texas 779 MEDICAL HISTORY (please print) LAST NAME FIRST NAME M F DOB REASON FOR VISIT MEDICATIONS Please list all the medications you are currently taking, including strength and number of times per day taken. MEDICAL HISTORY Please mark any of the diagnoses that apply to you, please include the year you were diagnosed. Acid Reflux Coronary Artery Disease Migraine Headaches Allergic Rhinitis Depression Osteoarthritis Anxiety Diabetes Pacemaker Asthma Emphysema Seizure Disorder Atrial Fibrillation Gout Thyroid Disease Attention Deficit Hepatitis Cancer (Breast, Ovary, Uterine) High Blood Pressure Cancer (Lung) High Cholesterol Cancer (Prostate) HIV/AIDS Congestive Heart Failure Irritable Bowel Syndrome DRUG ALLERGIES If you are allergic to any medications please write the name of the medication and the type of reaction you have to the medication. Anesthetics Aspirin Codeine Latex Penicillin Sulfa Other, please explain No Allergies
2 97 Kingwood Dr., BLDG. 6 Kingwood, Texas 779 SURGICAL HISTORY Please mark any of the surgeries that apply to you and give the year it was done. Appendix Heart Bypass Tonsillectomy Artery Bypass Hysterectomy Osteoarthritis Balloon Angioplasty Knee Surgery Tubal Ligation Cardiac stent Mastectomy Seizure Disorder Colon Surgery Organ Transplant Valve Replacement Disc Surgery PE Tubes Vasectomy Facial Surgery Prostate Surgery Breast Implants Gallbladder Splenectomy Liposuction FAMILY HISTORY Please mark the disease and circle the family member who has had this disease. (F= Father, M= Mother, B= Brother, S= Sister, GP= Grandparent) Breast Cancer M S GP Heart Disease F M B/S GP Adopted Colon Cancer F M B/S GP Melanoma F M B/S GP Thyroid disease F M B/S GP Diabetes F M B/S GP Prostate Cancer F B GP SOCIAL HISTORY We would like to get to know you better, please fill out the information below. Marital Status Married Single Divorced Widowed Occupation Name of Spouse Names of Children Exercise per week Smoking No Yes (packs/day) Alcohol No Yes (drinks per day) HEALTH HISTORY Do you have a living will? No Yes Date last reviewed When was your last complete physical? When was your last Tetanus booster? Have you received a pneumonia vaccine? No Yes Date of vaccine
3 97 Kingwood Dr., BLDG. 6 Kingwood, Texas 779 MEN AND WOMEN OVER AGE 5 When did you last have: A stool specimen tested for blood/cancer? No Yes A colonoscopy or sigmoidoscopy to check for colon cancer? No Yes An exercise stress test? No Yes An EKG? No Yes FOR MEN OVER 5 When was your last PSA blood test? No Yes FOR WOMEN ONLY Are you pregnant? No Yes If yes, how far along? When was your last mammogram? No Yes At which facility When was your last pap smear? No Yes Performed by: When was your last bone density scan? No Yes When was the first day of your last menstrual period? What form of contraception do you currently use? No Yes QUESTIONS RELATING TO SKIN/SKIN CARE YES NO Have you ever had herpes, cold sores, fever blisters, keloids, or hives? Circle any yes answer YES NO Is your family prone to vascular blemishes? Spider Veins Varicose leg veins Cherry Angioma Facial Capillaries Rosacea YES NO Have you ever visited a dermatologist, plastic surgeon, cosmetic dentist, or other skin care clinic? List YES NO Have you ever used Retin-A or a similar product? YES NO Do you use skin products such as moisturizer, cleanser? What Brand? YES NO Do you suntan? YES NO Do you use sunscreen? Is your skin: Dry Oily Normal Combination Are you: Fair Olive Asian Hispanic Native American African American? What are your concerns with your skin? Patient Signature Date Provider Date
4 97 Kingwood Dr., BLDG. 6 Kingwood, Texas 779 Please answer the following questions by circling the number which best describes you. Your clinician will total the score during the consultation. If skin type V or VI: You need to schedule a SKIN SPOT TEST (Which would mean you have to come in for a consult). My eye color is: My natural hair color at age 8 was: The color of my skin that is not normally exposed to sun is: If I go into the sun for an hour or so without sunscreen and have not been in the sun for weeks, my skin will: When was the last time the area to be treated was exposed to sunlight, tanning booths or tanning cream: Light Blue Blue/Green Green/Gray/Golden Hazel/Light Brown Brown Red Blonde Light Brown Medium to Dark Brown Black Pink to Reddish Very Pale Pale with a Beige tint Light Brown Medium to Dark Brown Dark Brown/Black Burn, Blister and Peel Burn, little or no color change Burn, then tan Get pink, then tan Just tan Just gets darker My skin color is dark Longer than one month ago Within the past month Within the past two weeks Within the past week If your score is: Your skin type is: Total Score: - I -7 II 8- III -5 IV 6-9 V - VI
5 97 Kingwood Dr., BLDG. 6 Kingwood, Texas 779 PATIENT CONSENT FORM Consent for the taking and publication of photographs, videotape, and/or computer images I,, hereby consent that photographs, videotape, and/or computer imaging may be taken of me or of parts of my body under the following conditions: Pre-treatment and post-treatment photographs will be taken of my treatment for medical record purposes. The photographs will be taken by my physician or staff member of my physician. I understand that these photographs will be the property of the attending physician and Kingwood. Pre-treatment and post-treatment photographs will be taken of my treatment for medical record purposes. Such photographs and/or videotape shall be used only for medical records, teaching, publication, marketing, or scientific research by my physician and Kingwood, provided that in any such publication the use of my name and identity is kept confidential and protected. Such photographs may be edited at the discretion of my physician to protect my confidentiality or emphasize the treated area. I have had the opportunity to discuss this consent with my attending physician or a qualified staff member of Kingwood. I agree that all of my questions have been answered. I hereby waive all rights I might have to such photographs, videotape, and computer images and do hereby release, discharge, and save harmless my physician & Kingwood and their respective managers & employees from all such claims and liabilities whatsoever in law and in equity arising from the use of such photographs, videotape and computer images described above. I have declined having any photos taken by my attending physician or any staff of Kingwood. By signing below, I am indicating that I understand that I will be unable to visualize the treatment changes over time. I have read and fully understand this Photo/Video/Computer Imaging Consent and agree to all of its terms. Patient Signature, Date Witness Signature, Date
Name: Date: DOB: Phone: Service: Notes:
Name: Date: DOB: Phone: Email: Service: Notes: ` TODAY S DATE REFERAL NAME/LAST FIRST M F DOB (OPTIONAL) ADDRESS CITY STATE ZIP PHONES/HOME WORK CELL EMAIL ADDRESS FAX NUMBER HEIGHT FT IN WEIGHT OCCUPATION
Comprehensive Patient History Form
Comprehensive Patient History Form Date: Name: D.O.B. Past Medical History: (check all that apply) Acid Reflux Cataracts Heart disease Migraines Alcohol or Drug Problem Colitis/Crohns Heart valve problems
Adult Health History for New Patient
Adult Health History for New Patient Name: Birth Date: Today s Date: Preferred Pharmacy (name and location): Your answers on this form will help your health care provider get an accurate history of your
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
Patient Information. First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( )
Today's : Patient Information First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( ) Email: Work Phone: ( ) Primary Care Physican: Cell Phone: (
PATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
PATIENT INFORMATION Name: First Name MI Last Name Date of Birth: / / Sex: Male / Female / Declined SSN: Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Declined Marital Status: Single Married Divorced/Separated
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
FROST FAMILY MEDICINE
Patient Information (Please Sign and return to Receptionist) Home Phone Day Phone Cell Phone E-mail Driver s License # Preferred Language Race Soc Sec # Gender: Male Female Marital Status: Single Married
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Reason for visit: Previous and/or Maiden Name: Parent/Guardian Name if patient is minor: Birth date: (M/D/Yr) Gender: Male Female SSN (patient): SSN (guardian, if patient is minor):
NAME DATE Page 1. Other. Kidney Removed (Right, Left) Bladder Removed. Ovaries Removed for Endometriosis Breast Biopsy
NAME DATE Page 1 Past Medical History: (please circle ALL that apply) Anxiety Hepatitis Arthritis Hypertension Artificial joints HIV/AIDS Asthma Hypercholesterolemia Atrial fibrillation Hyperthyroidism
EMERGENCY CONTACT INFORMATION: Name of contact: Address: Phone#: Relationship: May we release medical information to this person?
! Page 1 of 5 PATIENT INFORMATION: NAME (Nombre): DATE OF BIRTH (Fecha de Nacimiento): ADDRESS (Direccion): CITY (Ciudad): STATE(Estado): ZIP(Codigo Postal): TELEPHONE (HOME)(# Casa): CELL(# Celular):
SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:
Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone
Date Patient Last Name First Name Middle Name Gender (circle): Male Female Other: Marital Status (circle): Single Married Divorced Widowed Separated Home Address City State Zip Date of Birth Age Social
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
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Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
Patient Interview Form
Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more White Unknown
Is there any person (including your spouse) that you would like medical information released to? If so please give the following information:
(PLEASE PRINT) Date: Patient Information: Home Phone: Cell Phone: Name: Last Name First Name M.I. Mailing Address: City: State: Zip: Birth Sex: M F Age: Birth date: Status: Married Widowed Single Separated
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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
San Luis Dermatology & Laser Clinic, Inc.
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To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
New Patient Paperwork
Name (Last, First, M.I.): M F Email Address: Primary Phone: Race: Today's Date: DOB: Alternate Emergency Phone: Contact: American Indian/Alaska Native Asian African American Caucasian Nat Hawaiian/Pacific
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Preferred Pharmacy. Past Medical History
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Phone Number (day): Phone Number (evening): Email Address: Emergency Contact: Preferred Pharmacy Name: Phone Number: City and
*** ADDRESS: (If address is not provided, you MUST write Patient denied.)
PATIENT INFORMATION NORTHWEST BROWARD ORTHOPAEDICS DATE: ***E-MAIL ADDRESS: (If e-mail address is not provided, you MUST write Patient denied.) Pharmacy Name: Pharmacy Phone Number: Pharmacy Location PATIENT
Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire
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SLRHC Cardiovascular Prevention Program - Cardiovascular Health Questionnaire
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Patient or Parent/ Guardian Signature Date
Today s Date Appointment Date Last Name First Name Middle Initial Birthdate Age Title: (circle one) Mr. Mrs. Dr. Ms. Miss Sex: (circle one) M F Home Phone Cell Work Email Primary Insurance ID number Subscriber
Patient Interview Form
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Primary Care Clinic Adult Patient Demographics
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INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service.
CYNTHIA B. YALOWITZ, M.D., F.A.A.D.
Adult and Pediatric Dermatology Cosmetic Dermatology 3 NORTH AVENUE PHONE: (914) 833-3030, FAX (914) 833-3034 PAST MEDICAL HISTORY PLEASE CIRCLE ALL THAT APPLY. Select any of the following medical conditions
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o Kidney Cancer o Liver Cancer o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine o Neurological
Adult New Patient Registration PATIENT DOB: / / MONTH DAY YEAR PATIENT NAME: LAST FIRST MI o Abnormal Heartbeat Patient Medical History: Please mark all that apply o Chronic Headaches o Hepatitis C o Neuropathy
Emergency Contact Name Relationship Phone Primary Care Physician Phone Did a Physician Refer you to us? YES NO Physician Name
TELL US ABOUT YOU (please print) First MI Last Address 1 Address 2 CITY ST ZIP COUNTRY E-mail Opt out of providing E-mail Address Language Preference SSN - - DOB / / Driver s License # ST Phone 1 CELL
HEMATOLOGY / ONCOLOGY PATIENT HEALTH HISTORY
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
TO SERVE YOU MORE EFFICIENTLY, PLEASE COMPLETE THIS FORM AND RETURN IT TO THE FRONT DESK BEFORE YOU ARE CALLED TO AN EXAM ROOM. THANK YOU.
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New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
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PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:
1 NAME: DATE OF BIRTH PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS: PAST MEDICAL HISTORY (YOUR MEDICAL HISTORY) :
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Past Medical History: (please mark the medical conditions that you currently have) Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH Breast Cancer Colon Cancer COPD Coronary Artery
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Welcome to the Healthplex! Program Please check program that applies to you. If unsure, please ask our staff. Aftercare Employee Health Pulmonary Rehab Lung Gym Cardiac Rehab Health Improvement Prenatal/Post-Partum
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Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
Date: PATIENT INFORMATION Name SS# LAST FIRST MIDDLE INITIAL. Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed
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Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU**
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Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Home Phone #: Work Phone #: Cell
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Intake and History Form
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Soc. Sec. #: Phone Number (day): Phone Number (day): Email Address: Emergency Contact: # Preferred Language: _ Race: Ethnic Group:
Patient Information. First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( )
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Patient registration
Patient registration Name: DOB: Sex: Date: Who referred you to our office? Other Physicians you see: Occupation: Place of Employment: Marital Status (Please Circle): Single Married Separated Divorced Widowed
Medical History Record
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PATIENT HEALTH HISTORY
Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
Date: New Patient Form First Visit Date:
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N N N N N N N N N N N N N N N N N N N N N N N
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Health History Intake Form;
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Patient Registration Form
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LIST ALL CURRENT MEDICATIONS BELOW INCLUDING INJECTIONS/INFUSION MEDICINES MEDS) Name of Medication Dose How often taken
Please take a moment to fill out the following forms front and back: Pharmacy Information: (Include the Name, Address and Phone Number of the Pharmacy) Preferred Local: Preferred Mail Order/Specialty:
HISTORY AND INTAKE FORM
PATIENT NAME: HISTORY AND INTAKE FORM DOB: DATE: Asthma Atrial fibrillation Bone marrow transplantation Breast cancer Colon cancer COPD Coronary artery disease (heart disease) Diabetes End stage renal
Mailing Address: Street City Zip
First Middle Last Mailing Address: Primary Phone: Street City Zip Secondary Phone: Date of Birth: Male Female SSN: Emergency Contact Phone: Marital Status: Single Race: American Indian or Alaska Native
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
Hormone Consultation for Women
Healthway Compounding Pharmacy 2544 McLeod Dr. N., Ste. 2 Saginaw, MI 48604 989-791-1691 Toll Free: 866-883-8868 Fax: 989-791-4603 Hormone Consultation for Women Today s Date: / / Patient Name: Birth date:
6140 W Atlantic Avenue * Delray Beach, FL Tel: (561) * (888) 357-DERM * Fax: (561)
Cosmetic Patient Information Today s Date: Reason for visit: Patient Name: (Last) (First) (Middle) Permanent Address (Local): Street City/State/Zip Secondary (Out of State) Address: Street City/State/Zip
Last Name First Name MI SS# DOB. Address. City State Zip. Best Phone# (home/ work/ cell) Alternate # (home/ work/ cell)
39 th and Market Street, Penn Presbyterian Medical Center, MOB 340 Philadelphia, PA 19104 215-662-9775 823 South 9 th Street, 1 st Floor Philadelphia, PA 19147 267-239-2725 Last Name First Name MI SS#
LASER QUESTIONNAIRE FORM
LASER QUESTIONNAIRE FORM Patient Name: Today s Date: Date of Birth: Cell Phone: Age: Home Phone: Main Concern that brought you into our office today for laser treatments: Acne Wrinkles Scarring Sun Spots
Patient Health Forms
Patient Health Forms All forms MUST be completed and signed prior to seeing the Provider First: M: Last: Email Address: Home Address: Best Phone Number to Reach You: Last 4 of your social security #: Marital
Lehigh Valley Physician Group
Lehigh Valley Physician Group Welcome to LVPG Obstetrics and Gynecology We are pleased you have selected LVPG Obstetrics and Gynecology for your obstetrical / gynecological care. Meeting a new medical