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
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- Daisy Nash
- 5 years ago
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1 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 o Sleep Apnea o Alcoholism o Colon Cancer o High Blood o Osteoporosis Pressure o Anemia o COPD o High Cholesterol o Ovarian Cancer o Stroke o Stomach Cancer o Anxiety/Panic o Dementia o HIV/AIDS o Pancreatic Cancer o Thyroid Attacks Disease o Arthritis o Depression o IBS o Parkinson Disease o TIA o Asthma o Atrial Fibrillation o Diabetes, Childhood o Diabetes, Adult Onset o Kidney Cancer o Liver Cancer o Passing Out/ Fainting o Peptic Ulcer Disease o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine Cancer o Bladder Cancer o Fibromyalgia o Lung Cancer o Prostate Cancer o Vertigo o Bleeding Disorder o Glaucoma o Lymphoma o Rectal Cancer o None o Blood Clots o Head/Neck Cancer o Macular Degeneration o Skin Cancer o Brain Cancer o Heart Disease o Melanoma o Seizures/Epilepsy o Breast Cancer o Heartburn o Mental Illness o Severe Anesthesia Complications o Cervical Cancer o Hepatitis A o Multiple Sclerosis o Sexually Transmitted Diseases o Chronic Back/ Neck Pain o Hepatitis B o Neurological Disease o Shingles Patient Surgical History: Please mark all that apply o Heart Bypass o Pacemaker/Defibrillator o Heart Stent o Heart Valve Replacement o Brain Aneurysm o Carotid Artery o Leg Artery o Brain Tumor o Other Cancer o Transplant o Orthopedic (Bone) o Joint Replacement o Hysterectomy o Gallbladder o Cataract Removal o Weight Loss Surgery o Carpal Tunnel Release o Lumbar Spine o Cervical Spine o None Page 1 of 6
2 Prior Neurodiagnostic Testing: Please mark all that apply MRI o Head o Neck o Lumbar CT o Head o Neck o Lumbar o Oregon Imaging Center o Willamette Valley Imaging o Sacred Heart Hospital o McKenzie-Willamette Hospital NCV/EMG EEG o Sacred Heart Hospital o McKenzie-Willamette Hospital Family History o Family History is unknown (if yes, skip to Social History) o Family History is unremarkable Coronary Heart Disease (CHD): please check all that apply o No Family History of CHD Yes, Family History of CHD in: o Father, younger than 55 o Brother, younger than 55 o Son, younger than 55 o Mother, younger than 65 o Sister, younger than 65 o Daughter, younger than 65 Page 2 of 6
3 Family History Please mark all that apply: Father Mother Sibling Grandparent Abnormal Heartbeat o o o o Alcoholism o o o o Atrial Fibrillation o o o o B12 Deficiency o o o o Blood Clots o o o o Brain Cancer o o o o Breast Cancer o o o o Chronic Headaches o o o o Colon Cancer o o o o Dementia o o o o Depression o o o o Diabetes o o o o Heart Disease o o o o High Blood Pressure o o o o High Cholesterol o o o o Lung Cancer o o o o Lymphoma o o o o Melanoma o o o o Mental Illness o o o o Multiple Sclerosis o o o o Neurological Disease o o o o Neuropathy o o o o Parkinson Disease o o o o Passing Out/Fainting o o o o Pituitary Tumor o o o o Prostate Cancer o o o o Seizures/Epilepsy o o o o Stroke o o o o Thyroid Disease o o o o TIA o o o o Tremor o o o o Social History Women Only: Do you use birth control? (circle one) YES NO Are you pregnant? (circle one) YES NO Are you considering becoming pregnant? (circle one) YES NO Page 3 of 6
4 Do you have children? (circle one) YES NO Social History Status of Mother: (circle one) ALIVE DECEASED UNKNOWN If deceased, died of: Age at death: Status of Father: (circle one) ALIVE DECEASED UNKNOWN If deceased, died of: Age at death: Tobacco Use: (circle one) Never Former Current If current or former tobacco user: (circle one) Cigarettes Smokeless Tobacco Year Started: Current Packs/Day: Year Quit: Previous Packs/Day: Alcohol Use: How often have you had a drink containing alcohol in the past year? o Never o Monthly or Less o 2-4 times a month o 2 or 3 times a week o +4 times a week How many drinks do you have on a typical day when you were drinking in the past year? o 1 or 2 o 3 or 4 o 5 or 6 o 7 to 9 o + 10 How often did you have 6 or more drinks on one occasion during the past year? o Never o Less than monthly o Monthly o Weekly o Daily o Almost Daily Drug Use: (circle one) Never Previous Current If current or previous, which ones? (mark all that apply) o Heroin o Methamphetamine o Cocaine o Marijuana o Illicit Prescriptions Caffeine Use, daily: o 0-1 cups o 2-3 cups o 4-5 cups o + 6 cups Marital Status: o Married o Single o Divorced o Widowed o Domestic Partner Employment Status: o Part-Time o Full-Time o Homemaker o Unemployed o Disabled o Retired Page 4 of 6
5 Education Level: o 8 th grade or less o High School o Some college Social History o Two year degree o Four year degree o Graduate School Patient s Dominant Hand: o Left o Right Page 5 of 6
6 Medications Please list all prescription and over-the-counter medications you are taking at this time Name of Medication Dosage/Strength # Per Day Allergies Please list all allergies (including environmental, medication, and food) Demographic Information: Preferred Language o English o Spanish Ethnicity o Hispanic or Latino o NOT Hispanic or Latino o Declined Race o American Indian o Asian o Black or African American o Native Hawaiian o White o Declined Page 6 of 6
7
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
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):
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
NEUROSURGERY PATIENT INTAKE FORM
NEUROSURGERY PATIENT INTAKE FORM Surgical Movement Disorders Center Name: DOB: / / Age: Gender: Male Female (circle one) Height: feet inches Weight: lbs What is the main reason for your visit? Are there
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
KAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM
KAREN J. SUNDBY, M.D. PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM Dr. Mr. Mrs. Ms. Miss New Patient or Returning Patient FULL LEGAL NAME: Reason for today s visit: Mohs Excision Skin Check other:
Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:
Tel: (312) 694-7337 Women s Integrated Fax: (312) 695-0156 Pelvic Health Program 1.0: Basic Information Date of Birth: / / Age: Home Address: Preferred Language: English Spanish Other: Email address: Preferred
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
NOTICE TO OUR PATIENTS
SMG Chestnut Street, SMG Elm Street, SMG Mancos Valley, Southwest Walk-In Care, Southwest School-Based Health Center, SMG Market Street, SMG Orthopedics, SMG Pulmonary and Sleep Medicine, SMG General Surgery,
How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all
Family Health History Please answer each question as honestly as possible. There are no right or wrong answers to nay of the questions. It is important that you answer as many questions as you can. We
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
MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History
MEDICAL INFORMATION TODAY S DATE: SOCIAL SECURITY NUMBER: PATIENT NAME: BIRTHDAY: HEIGHT: WEIGHT: AGE: WHO REFERRED YOU? RACE: PRIMARY CARE PHYSICIAN: SEX: DOCTOR S ADDRESS: SECTION 1: Pharmacy Information
GIDEON G. LEWIS, M.D.
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New Patient Medical Questionnaire DATE:
New Patient Medical Questionnaire DATE: Patient Name: DOB: AGE: Other Physicians: Who can we thank for referring you to our practice? Pharmacy Name & Location:` Phone # CHIEF COMPLAINT What problems are
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 INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
Primary Care Clinic Adult Patient Demographics
Primary Care Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) -
Clinic Adult Patient Demographics
Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) - May we leave
MEDICAL HISTORY. Previous Nephrologist. Medication taken Insulin Oral Both. Who manages your diabetes? Blindness Yes No Hearing Problems Yes No
MEDICAL HISTORY Please mark YES or NO and fill in appropriate blanks as needed Chronic Yes No If yes, year diagnosed Previous Nephrologist Transplant Yes No If yes, date Donor type Living Deceased Related
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
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / / Email Address: Do not have email Do not wish to provide Date of Birth: / / Gender: Male
Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
Patient Name (First, Middle, Last) Height Weight Date of Birth Social Security # Gender Male Female Ethnicity Race Language Address City State Zip Home Phone Cell Phone Work Phone Other Phone Email Occupation
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
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Patient Interview Form
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Patient Interview Form
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Patient Name: Date of Birth:
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PATIENT DEMOGRAPHIC INFORMATION
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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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(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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DEMOGRAPHICS Date of Birth: Age: years Gender: Male Height: inches Female Weight: lbs Handed: Right BMI: Left Ambidextrous Race: choose only one Ethnicity: Marital Status: African American / African Heritage
WELCOME TO OUR OFFICE
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
PATIENT REGISTRATION
PATIENT REGISTRATION "Please PRINT clearly and fill out form COMPLETELY and hand all insurance cards for copying ** First Name: Last Name: Middle Initial: Address: Apt #: City: State: Zip: Date of Birth:
Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E mail newsletters, reminders, statements, etc. Emergency Name: Phone: City: State: Zip: Home
Health History Intake Form;
Health History Intake Form; Today s Date: Patient Name: Date of Birth: Age: Previous Primary Care Physician (if any): Phone: Address: Other Physicians involved in your care: Reason for visit today: Allergies
CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:
JOSE G. VELIZ MD, INC. Diplomate of the American Board of Interventional Pain Management Diplomate of the American Board of Anesthesiology Diplomate of the American Board of Pain Medicine Fellow of Interventional