Primary Care Physician Physician Name: Phone: Fax: Address:
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- Alicia Ross
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1 Page 1 of 6 Demographics Name: _ (First, Middle Initial, Last) Date of birth: Age: Gender: Male Female Marital Status: Married Single Divorced Widowed Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: Emergency Contact: Relationship: Phone: What numbers can we leave messages at and with whom? Ethnicity: (Check all that apply) African-American Hispanic Asian Caucasian Native American or Alaska Native Native Hawaiian or Pacific Islander Other Primary Care Physician Physician Name: Phone: Fax: Address: Employee Status: Full Time (at least 35 hours a week) Part-time Self Employed Homemaker Student Retired Disabled Employer Name: Occupation: Primary Insurance Information Name: Insurance _ Company Name: Subscriber s name: Gender: Male Female Date of Birth: Insurance ID Number: Group Number: Effective Date: Relationship to patient: Subscriber s employer: Secondary Insurance Information Name: Insurance _ Company Name: Subscriber s name: Gender: Male Female Date of Birth: Insurance ID Number: Group Number: Effective Date: Relationship to patient: Subscriber s employer:
2 Page 2 of 6 Height: Weight: Nutritional Evaluation BMI: (for office staff to complete)! 1. Are you diabetic? Yes No 2. How many years ago did you begin to have issues related to your weight? 3. How many years have you been obese? 4. What was your highest adult weight? Age you reached this weight? 5. What was your lowest adult weight? Age you reached this weight? 6. What weight loss methods have you tried? (circle all that apply) Diets Medications Behavioral Medical Weight Loss Atkins Meridia Hypnosis Physician Prescribed diet LA Weight Loss Orlistat (Xenical) Counseling Optifast Jenny Craig FenPhen Acupuncture HMR Weight Watchers Adipex Other: Other: Overeaters Anonymous HCG Injections Nutrisystem Dexatrim Bariatrix Trim Spa Other: Metabolife Stacker III Other: What is the average length of time you stayed on a diet? What was your average weight loss while on a diet? What is the average length of time you were able to maintain your weight loss? 7. Have any of your relatives had weight loss surgery? Yes No If yes, what type of surgery? What is their relationship to you? 8. Do you have a history of food allergies or intolerances? Yes No If yes, what kind? Lactose Fructose Gluten Nuts Shellfish Other: 9. Do you consume beverages containing caffeine, carbonation, and/or calories? Yes No If yes, what type and amount? 10. Do you exercise? Yes No If yes, what type and amount? 11. Check which meals you eat regularly: Breakfast Lunch Supper/Dinner Snacks 12. Provide the names of your favorite restaurants or fast food places: 13. How often do you eat meals that have been prepared away from your home kitchen? Daily Weekly 1-3 times a month Infrequently 14. Who prepares your meals in your home? 15. Who does the food shopping?
3 Page 3 of 6 Medication and Allergies 1. Do you have a latex allergy? Yes No If yes, what reaction does the latex allergy cause? 2. Drug Allergies Drug Name Reaction 3. List all current Medications (including vitamins, herbal supplements, aspirin, inhalers and over-the-counter medication) Drug name Dose How often do you take? Name of the pharmacy you use: Phone: Medical History (Please check any of the following medical conditions your currently have) Diabetes High Blood Pressure High Cholesterol Sleep Apnea Arthritis Gastric Reflux Asthma Urine Leakage Depression Polycystic Ovarian Syndrome (PCOS) Other: What procedure are you interested in? Gastric Bypass Sleeve Adjustable Band Why are you considering having bariatric surgery?
4 Page 4 of 6 Surgical History Do you have a history of: If yes, describe and provide date of surgery Heart bypass/stent Yes Heart Valve Replacement Yes Pacemaker Yes Lung Surgery Yes Breast Surgery Yes Bowel Surgery Yes Gallbladder Removal Yes Hernia Repair Yes Hysterectomy Yes Prostate Surgery Yes Hip Surgery Yes Knee Surgery Yes Gastric Surgery Yes Anti-Reflux Surgery Yes Other Yes Social History Do you live: Alone With others: Do you have a spiritual/cultural need that we need to know in order to care for you? No Yes: Do you smoke or use tobacco products? No, never No, quit months/years ago Yes, how much? months/years Do you use alcohol? No Yes, how many drinks do you have per week? Do you use any non-prescribed drugs No Yes, how much/how often/type? Family History Please check which, if any, of your family members had any of the following conditions: Condition Sibling Mother Father Grandparent Aunt/Uncle Comments Anemia Bleeding Blood clots Cancer Diabetes Gallstones Gout Heart Disease High Blood Pressure Kidney Disease Obesity Sleep Apnea Stroke
5 Page 5 of 6 Past Medical History (Please circle any symptom you are having presently or in the past six months) GENERAL: Weight gain, Weight loss, Fever, Chills, Sweats, Fatigue HEAD: Headaches, History of head injury, Dizziness, Fainting EYES: EARS: NOSE/THROAT: LUNGS: HEART: ABDOMEN: NEUROLOGICAL: SKIN: ENDOCRINE: BLOOD/GLANDS: EMOTIONAL: ALLERGIC: IMMUNOLOGIC LIVER: RENAL: MEN- URINARY: Jaundice (yellow color), Visual changes, Double vision, Glaucoma, Cataracts, Glasses or contacts Ringing, Hearing loss, Infections, Drainage, Pain, Hearing aid, Balance problems Sinus congestion, Nose Bleeding, Sinus Infection, Gum bleeding, Soreness, Dentures, Hoarseness or voice changes, Swallowing difficulties, Chewing difficulties Shortness of breath, Cough, Wheezing, Asthma, Coughing up blood, Tuberculosis or exposure, Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Sleep Apnea, Supplemental oxygen Chest pain (angina), Rapid heart rate, Irregular heart rate, Atrial Fibrillation, Exertional shortness of breath, Shortness of Breath lying flat, Sudden Shortness of Breath at night, Heart attack, Mitral Valve Prolapse, High Blood Pressure, Leg swelling, Palpitations, Murmurs, Rheumatic Fever, Pacemaker Stomach pains, Nausea, Vomiting, Diarrhea, Constipation, Change in bowel habits, Black stools, Blood in Stool, Reflux, Heartburn, Ulcers, Rectal pain, Rectal bleeding, Pancreatitis, Hepatitis, Jaundice, Gallbladder problems, Crohn s Disease, Ulcerative Colitis Dizziness, Loss of consciousness, Stroke, Ministrokes (TIAs), Seizures, Numbness, Weakness, and Headaches Rashes, Non healing or changing lesions, Skin cancers, Leg ulcers Thyroid problem, Heat or Cold intolerance, Type I Diabetes, Type II Diabetes, Borderline Diabetes, Gestational Diabetes, High Cholesterol/Lipids Anemia, Easy bruising, Easy bleeding, Swollen glands, Sickle cell, Lymphoma, Cancer, Coumadin usage, Blood clots Nervousness, Anxiety, Mood swings, Depression, Bipolar Disorder Hay Fever, Environmental allergies HIV, Hepatitis, Gallbladder, Lupus, Rheumatoid problems Kidney disease, Kidney failure, Stones, Dialysis Difficulty urinating, Trouble holding urine, Up at night to urinate, Excessive Thirst, Excessive urination, Blood in urine, Discharge from penis, Infections, Pain with urinating, Hesitancy, Dribbling or poor stream WOMEN: Age of first menstrual period: Last menstrual period: Number of pregnancies: Age at first full term pregnancy: Menopause since: Abortions: Do you perform breast exams: Yes/No Personal family history of breast/ovarian cancer: Last mammogram (month/year): Last gynecologic exam: Estrogen use (past or present): Breast mass, Nipple discharge, abnormal mammogram, Breast augmentation, Difficulty urinating, Blood urine, abnormal periods, Incontinence, Infections, Pain with urination, Polycystic Ovarian Syndrome (PCOS), Leakage of urine, Pelvic Prolapse
6 Page 6 of 6 Pain History Do you have a pain problem? No Yes If yes, is your pain new or chronic? Where is your pain located? Please describe the character of the pain (example: burning, sharp, stinging, aching) What is your level of pain on a scale from 0 to 10 (0=no pain, 10=worst imaginable) What do you do to relieve the pain? medication Rest Positioning other: If medication, what type? Does your pain relief method work? Yes No Learning Needs Highest Level of Education: Preference for learning: Reading information Hands on practice One on one discussion Language Preference: English Other: Advance Directives Do you have an Advance Directive or Living Will? Do you want information regarding Advance Directives? No Yes Patient Signature: Date: Time: FOR OFFICE USE ONLY Clinical Staff Reviewing (Physician/CRNP/RN/PA-C): Signature Date: Time:
Gender: M F Race: Caucasian African American Hispanic Other
Weight Loss Surgery Patient Information First Name: Middle Initial: Last: Date of Birth: Age: Social Security #: Gender: M F Race: Caucasian African American Hispanic Other Address: City: State: Zip: Home
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New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
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:
RHEUMATOLOGY PATIENT HISTORY FORM
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Patient Interview Form
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Cell Phone #: Home Phone #: ** Address (prefer your forever address):
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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:
/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
SURGICAL WEIGHT MANAGEMENT ASSOCIATES
SURGICAL WEIGHT MANAGEMENT ASSOCIATES Restoring Health Renewing Lives Eric Rau MD Fritz Rau MD David Rau MD Donald Schwab Jr MD 5619 Hwy 311 Ste B Houma, LA 70360 Phone 985-868-2206 Fax 985-868-2232 www.surgicalweightmanagement.com
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.
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
Wynne Huang, M.D. Family Medicine
PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: SS#: - - Address: City, State, Zip Code Single( ) Married( ) Partner( ) Divorced( ) Widowed( ) Legally Separated( ) Male( ) Female(
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
Patient Interview Form
Page 1 of 5 Gastroenterologists: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Samuel J. Tarwater, MD Travis J. Rutland, MD Gastroenterologists: Marc L.
DNA CENTER New Patient Information
DNA CENTER New Patient Information Name Email: Address City State Zip Home Phone Work Cell Phone Social Security Number Date of birth Gender ( Male/Female) Age Please Circle: Hispanic/Latin or Non Hispanic/Latin
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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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
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
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:
Placer Private Physicians: Patient Health Questionnaire [2]
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Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
Surgical History Please list all operations and dates:
1 General Information *Please complete in blue or black ink only* Name: Date: Address: City: State: Zip Code: Date of Birth: Email: Telephone: (Cell) (Home) (Work) Referred by: Occupation: Primary Doctor: