PATIENT INFORMATION (Please print all information) Date:
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1 320 Lillington Ave Suite 101 Charlotte, NC Phone: Fax: Please fill out the following form completely so that we may obtain the necessary information for our files and background information on your medical problem. In this way, more time will be available for you to talk to the doctor at the time of your visit. All information is held in strict confidence and will NOT be released to anyone without your written consent. PATIENT INFORMATION (Please print all information) Date: Referring Physician: Phone Number: Primary Care Physician: Phone Number: Name: Date of Birth: Age: Mailing Address: Sex: Race: Home Phone: Cell Phone: SSN: Occupation: Employer: Work Phone: Emergency Contact Person: Relationship: Phone: Address: ALLERGIES: Please list any allergies that you have and your reaction: FAMILY HISTORY ONLY: Please circle yes or no for each item for family members only. If yes, please indicate their relationship to you on the line provided. Relationship Relationship Anemia Gallstones Breast Cancer Heart Disease Celiac Disease Hemochromatosis Cervical Cancer Hepatitis C Cirrhosis of Liver Irritable Bowel Syndrome Colon Cancer Ovarian Cancer Colon Polyps Pancreatic Cancer Crohn s Disease Pancreatitis Diabetes Peptic Ulcer Disease Esophageal Cancer Ulcerative Colitis Gastric Cancer Uterine Cancer Reaction to anesthesia
2 YOUR PAST MEDICAL HISTORY: Please circle yes or no for each item for yourself only. CANCER HEART (continuation) Breast Cancer High Blood Pressure Cervical Cancer Mitral Valve Prolapse Colon Cancer Palpitations Esophageal Cancer Rheumatic Fever Leukemia Pacemaker Liver Cancer BLOOD Lymphoma Anemia Ovarian Cancer Bleeding or clotting abnormalities Pancreatic Cancer Hemophilia Prostate Cancer VonWillebrands Stomach Cancer HIV / AIDS Uterine Cancer INTEGUMENTARY Eczema RENAL Melanoma Dialysis Psoriasis Kidney Failure NEUROLOGICAL MUSCULOESKELETAL Alzheimer/Dementia Fibromyalgia Brain Aneurysm Gout Migraines Lupus Myasthenia Gravis OsteoArthritis Seizures Osteoporosis Stroke Reynaud s Rheumatoid Arthritis RESPIRATORY Scleroderma Asthma Sjogrens COPD (Emphysema) Sleep Apnea PSYCHOLOGICAL Tuberculosis (TB) Anxiety Bipolar GASTROINTESTINAL Depression Angiodysplasia of GI Tract Obsessive Compulsive Disorder Barrett s Esophagus Esquisofrenia Celiac Disease Colon Plyps LIVER Crohn s Disease Cirrhosis Diverticulitis Fatty Liver Diverticulosis Hemochromatosis Hemorrhoids Hepatitis A IBS (Irritable Bowel Syndrome) Hepatitis B Pancreatitis Hepatitis C Peptic Ulcer Disease Jaundice yes Reflux Ulcerative Colitis HEART Congestive Heart Failure ENDOCRINOLOGY Endocarditis Diabetes, Type I (insulin needed) Heart Attack (Myocardial Infarction) Diabetes, Type II (pills needed) Heart Valve Disease Thyroid Disease
3 SURGERIES: Please circle yes or no for each item for yourself only. If yes, please indicate the date on the line provided. Month / Year Month / Yr GASTROINTESTINAL GU Appendectomy Bladder Surgery Capsule Endoscopy Cystectomy with Ileal Conduit Cholecystectomy (Gallbladder Removal) Kidney Removal (nephrectomy) Colon Surgery Prostate Removal (Prostatectomy) Colonoscopy Radiation for Prostate Cancer ERCP TURP EUS Gastric Bypass CARDIAC Gastric Surgery Abdominal Aneurysm Hiatal Hernia Repair Angioplasty Inguinal Hernia CABG (Coronary Bypass) Manometry Cardiac Catherization Pancreatic Surgery PEG Tube Placement FemPop bypass (Leg Arteries) Esplenectomy (removal of spleen) Heart Stent placed Heart Valve Replacement Surgery for Intestinal Adhesions Pacemaker Umbilical Hernia Defibrillator Upper Endoscopy (EGD) OTHER GYNECOLOGICAL C-Section Hysterectomy (Abdominal) Hysterectomy (Vaginal) Mastectomy (right) Mastectomy (left) Have you ever had a complication to Anesthesia? Mastectomia (both) YES NO Ovary Removal (right) Ovary Removal (left) Ovary Removal (both) SOCIAL HISTORY: Marital Status: Married Single Widow Divorced Use of Tobacco: Use of Alcohol: Use of Drugs: history of tobacco use History of alcohol use History of drug use History of tobacco use History of alcohol use History of drug use Packs per day Glasses daily IV drug abuse Years of use Glasses weekly Marijuana Year quit Glasses occasional Crack/Cocaine History of alcoholism Year quit
4 REVIEW OF SYSTEMS: Please circle yes for each symptom or disease diagnosed for you during the last 2 months. Circle no for all others. GENERAL RESPIRATORY Loss of Appetite/Anorexia Cough Fatigue Shortness of breath Fever Wheezing Night Sweats CARDIOVASCULAR Weight Gain in the last 3 months Chest pain Amount Weight loss in the last 3 months Edema/ swelling Amount Are you under any stress? Difficulty breathing while laying down Eye pain Palpitations SKIN Shortness of breath Skin Rash NEUROLOGICAL Incontinence Stool ENT Numbness Hoarseness Weakness Oral Ulcers Voice changes GASTROINTESTINAL Headache Frequent constipation Vision Problems Pain with bowel movement Loss of visión Pale, greasy, oily, or rancid stools Double vision Mucus in or on your stool Blurred vision Frequent diarrhea Black or sticky stools HEMATOLOGY Blood in or on your stools Enlarged Lymph des Vomit frequently Prolonged Bleeding Vomit blood or coffee grounds Bloating, belching, or excessive gas GENITOURINARY Difficult or painful swallowing Blood in urine Frequent heartburn or indigestion Painful urination Frequent stomach pain Recent changes in your bowel movement Jaundice (yellow eyes)
5 PATIENT MEDICATION LIST Please print! Medication list should include all over-the-counter and taken-as-needed medications. Local Pharmacy: Location: Mail Order Pharmacy: Medication Name Strength (mg) Number of Times Taken Daily Reason
Patient Interview Form
Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information
Patient Interview Form
Patient Interview Form Patient Information First Name: Last Name: Date of Birth: Age: Email Personal: Race Select one or more Referring Physician White Black or African Asian American Indian Native Hawaiian
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: MRN: Last Name: Date Of Birth: Contact Preference Email Telephone call- Work Telephone call - Home Email Please check one as your preferred
Patient Interview Form
Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: tes: Contact Preference Email Telephone call/leave message Patient declines to specify Email Please check one
Patient Interview Form
Page 1 of 5 Telephone: 703-698-8960 Fax: 703-828-0961 www.novagi.com Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Race Select one or more White Unknown Black or African
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
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 Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
Patient Interview Form
Page 1 of 5 Physicians: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Physicians: Samuel J. Tarwater, MD Travis J. Rutland, MD Ashwani Kapoor, MD Pathologist:
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PATIENT HISTORY FORM
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PATIENT INFORMATION. Are we currently seeing one of your family members at our practice, or have we previously? YES patient s name:
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1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
PATIENT HEALTH INFORMATION SHEET
. Norman J. Brodsky, M.D. Board Certified Michael D. Gauwitz, M.D. Diplomate, ABR Taghrid A. Altoos, M.D. Radiation Oncology Hiral K. Shah, M.D. PATIENT HEALTH INFORMATION SHEET NAME: DATE OF BIRTH: AGE:
Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced