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1 Patient: Date of Birth Past Medical History check all that apply Head Trauma Eyes Blindness Cataracts Glaucoma Wear glasses/contacts Ears Hearing aids Nose/Sinuses Allergic rhini s Sinus infec ons Mouth/Throat/Teeth Dentures Cardiovascular Aneurysm Angina [chest pain] Deep venous thrombosis (DVT) Dysrhythmia Hypertension (HTN) Murmur Myocardial infarc on (heart attack) Other heart disease Respiratory Bronchi s COPD Bronchitis/Emphysema Pleuri s Pneumonia Gastrointestinal Cirrhosis GERD Gallbladder disease Heartburn Hemorrhoids Hepa s Hiatal Hernia Jaundice Ulcer Genitourinary Hernia Incon nence Nephrolithiasis Other kidney disease Sexually transmi ed disease (STD) Urinary tract infec on (UTI) Musculoskeletal Gout Musculoskeletal injury Skin Derma s Mole(s) Other skin condi on(s) Psoriasis Neurological Epilepsy Seizures Severe headaches, migraines TIA Psychiatric Bipolar disorder Depression Hallucina ons, delusions Suicidal idea on Suicide attempts Endocrine Goiter Hyperlipidemia Hypothyroidism Thyroid disease Thyroidi s Diabetes, type 1 Diabetes, type 2 Heme/Onc Anemia Cancer Infectious HIV STDs (sexually transmi ed disease) Tuberculosis (disease) Tuberculosis (exposure) Other Not Listed: Past Surgical History check all that apply Aneurysm repair Appendectomy Back Surgery Bariatric surgery/gastric bypass Bilateral tubal liga on Breast resec on or mastectomy Coronary artery bypass graft (CABG) Caro d endarterectomy or stent Carpal tunnel release surgery Cataract/lens surgery Cesarean section Cholecystectomy/bile duct surgery Dilata on & cure age (D&C) Hemorrhoid surgery Hip arthroplasty Hip replacement Hysterectomy Inguinal hernia repair Knee arthroplasty (replacement) LASIK Laminectomy Nasal surgery PTCA/PCI Pacemaker/defibrillator Prostate surgery Prostatectomy Rotator cuff surgery Sinus surgery Skin cancer excision Spinal fusion TAH BSO, total abdominal hysterectomy bilateral salpingo oophorectomy TURP transurethral resection of the prostate Tonsillectomy or adenoidectomy Vasectomy Other Not Listed: Page 1 of 5
2 Family History Family history unknown Mother: Alive Deceased Unknown No Health Problem Bleeding disorder Coronary artery disease (< age 55) COPD Diabetes Heart A ack Heart Disease High cholesterol Hypertension Mental illness Osteoporosis Breast cancer Colon cancer Other cancer: Ovarian cancer Uterine cancer Father: Alive Deceased Unknown No Health Problem Bleeding disorder Coronary artery disease (< age 55) COPD Diabetes Heart Attack Heart Disease High cholesterol Hypertension Mental illness Osteoporosis Breast cancer Colon cancer Other cancer: Prostate cancer Social History check all that apply Tobacco Current every day smoker Current some day smoker Former smoker Heavy tobacco smoker Light tobacco smoker Never smoker Alcohol Do not drink Drink daily Frequently drink History of alcoholism Occasional drink Drug Abuse Intravenous drug use Illicit drug use No illict drug use Other Cannabis/Marijuana user Cigar smoker Chew tobacco Electronic Cigarette/Vapor user Review of Systems check all that apply Constitutional Eyes Ears Nose Mouth/Throat/Voice Neck Respiratory Cardiovascular Breast fever night sweats chills cold intolerance fatigue day me sleepiness weight gain weight loss increased thirst increased hunger/over eating anorexia change in vision loss of vision blurred vision double vision eye redness eye pain tearing pus discharge difficulty hearing hearing loss ear pain/ear ache ear drainage nnitus nasal conges on nasal discharge nose bleeding sneezing snoring lip sores mouth sores tongue sores sore throat difficulty swallowing painful swallowing gum bleeding dental problems hoarse voice change in voice quality neck pain neck s ffness neck lumps neck swelling difficulty or labored breathing cough cough produc ve of sputum coughing up blood wheezing chest pain rapid heart rate shortness of breath at rest shortness of breath with ac vity shortness of breath when lying flat shortness of breath at night leg/feet swelling varicose veins breast lump (past or present) breast pain nipple discharge Review of Systems, cont. check all that apply Page 2 of 5
3 Gastrointestinal Urinary Genital/Reproductive Dermatologic / Integumentary Musculoskeletal Neurological Psychiatric Hematologic/Lymphatic abdominal pain rectal pain nausea vomi ng vomiting blood decreased frequency of bowel movements cons pa on increased frequency of bowel movements diarrhea fecal incon nence clay colored stools greasy stools tarry stools blood in stool painful or difficult urina on blood in urine difficulty beginning the flow of urine difficulty maintaining urine stream urine dribbling increased need to urinate decreased need to urinate large urine output low urine output increased nigh me urina on frequent need to urinate despite low output urinary incon nence urinary incon nence with cough change in libido problems with sexual func on difficult or painful sexual intercourse difficulty achieving erec on difficulty maintaining erec on difficulty/inability reaching orgasm currently having menstrual cycles abnormally heavy bleeding during menstrua on bleeding between menstrual periods excess pain with menses irregular menses postmenopausal postmenopausal vaginal bleeding hot flashes change in hair texture change in skin texture change in nail appearance dry hair brittle hair hair loss dry skin itching hives rash bruising new moles skin sores skin lumps muscle pain back pain tender points muscle cramps muscle weakness decreased muscle strength limb paralysis difficulty walking limp headaches ver go lightheadedness fain ng blackouts numbness tingling tremor lack of coordina on weakness difficulty speaking memory loss difficulty concentrating change in mood depression sadness interfering with func on anxiety nervousness sleep disturbance suicidal idea on hopelessness worthlessness delusions hallucina ons easy bruising difficulty stopping blood flow lymph node enlargement lymph node tenderness Current Medications No medications Name of Medication Dose Frequency Allergies No allergies Allergy Reaction Severity (mild/moderate/severe) Page 3 of 5
4 Pain Medication History check all that apply NSAIDS/Anti inflammatories Improvement Side Effects/Type? Tylenol, acetaminophen, APAP Percogesic (acetaminophen + phenyltoloxamine) Percogesic (Mg salicylate) Aspirin (acetylsalicylic acid) Motrin, Advil, ibuprofen Duexis (ibuprofen + famotidine) Naprosyn, Aleve, naproxen, naprelan 500 Vimovo (naproxen + esomeprazole) Relafen, nabumetone Mobic, meloxicam Feldene, piroxicam Clinoril, sulindac Disalcid, salsalate Voltaren, diclofenac Arthrotec (diclofenac + misoprostol) Lodine, Etodolac Toradol, ketorolac Indocin, indomethacin Daypro, oxaprozin Celebrex, celecoxib Muscle Relaxers Improvement Side Effects/Type? Flexeril, cyclobenzaprine Robaxin, methocarbamol Baclofen, lioresal Zanaflex, tizanidine Skelaxin, metaxalone Dantrium, dantrolene Norflex, orphenadrine SOMA, carisoprodol Paraflex, chlorzoxazone Parafon Forte (chlorzoxazone + acetaminophen) Valium, diazepam Nerve Stabilizers Improvement Side Effects/Type? Neurontin, gabapentin Lyrica, pregabalin Topamax, topiramate Mexitil, mexiletine Tegretol, carbamazepine Trileptal, oxcarbazepine Lamictal, lamotrigine Analgesic Anti Depressants Improvement Side Effects/Type? Elavil, amitriptyline Pamelor, nortripyline Norpramin, desipramine Tofranil, imipramine Effexor, venlafaxine Cymbalta, duloxetine Savella, milnacipran Page 4 of 5
5 Pain Medication History check all that apply Topicals Improvement Side Effects/Type? Salonpas patches Thermacare patches Penetrex cream Capzasin, capsaicin cream Biofreeze, Sports cream (menthol + camphor) Voltaren gel Lidocaine Prilocaine cream Flector patch/diclofenac Lidoderm, lidocaine patches Compound cream Short Acting Opioids Improvement Side Effects/Type? Ultram, tramadol Ultracet (tramadol + APAP) T3, T4 (codeine + APAP) Talwin, pentazocine Talwin NX (pentazocine + naloxone) Stadol, Butorphanol Demerol, meperidine Vicodin, Lortab, Norco (hydrocodone + APAP) Percocet, Roxicet, Endocet (oxycodone + APAP) Roxicodone (oxycodone IR) Nucynta, tapentadol Dilaudid, hydromorphone Morphine IR Opana IR, oxymorphone IR Long Acting Opioids Improvement Side Effects/Type? Ultram ER, tramadol ER Butrans, buprenorphine patch Subutex, buprenorphine Suboxone (buprenorphine + naloxone) Nucynta ER, tapentadol ER Zohydro ER, hydrocodone ER Hysingla ER, hydrocodone ER MS Contin, Kadian, Avinza, morphine ER Oxycontin, oxycodone ER Opana ER, oxymorphone ER Exalgo ER, hydromorphone ER Duragesic, fentanyl patch Dolophine, methadone Levo Dromoran, levorphanol Page 5 of 5
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Northwest Georgia Surgical Specialists, PC PAST MEDICAL HISTORY
orthwest Georgia Surgical Specialists, PC Medical History Form ame Date of visit Last First MI Day ear Date of Birth Age Gender Marital Status Height Weight Day ear Referring Doctor Reason for Visit PAST
Patient History Form
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
Patient History Form
Acct #: Patient History Form Please answer ALL questions by filling out the appropriate box(es). Name: Gender: M F Primary Care Provider: DOB: Today s Date: Referring Provider (if different from PCP):
PATIENT INFORMATION (Please Print) Patient First Middle Initial Last. Birthdate: / / Patient Financially Responsible Yes No
PATIENT INFORMATION (Please Print) Date: Patient First Middle Initial Last Birthdate: / / Patient Financially Responsible Yes No Marital Status: Address: City: State: Zip Code: Primary Phone: ( ) (Circle
UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
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
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
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:
Health History. Personal Health History. Institute of Complementary Medicine. FOC Health History - ICM
Reason for office visit today FOC Health History - ICM Health History Whom may we thank for referring you today? Do you have another primary care provider? Date of last physical exam Previous or referring
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
Past Medical History. Chief Complaint: Appointment Date: Page 1
Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty
New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:
New Patient Packet Patient Name: DOB: Age: Sex: Male / Female Height: Weight: PHYSICIAN CARE Primary Care Physician: Address: City: State: Zip: Phone: Fax: Referring Physician (if different from PCP):