Admission note. Occupation: NIL. Abdominal pain on 1/1 morning, vomited bile content

Size: px
Start display at page:

Download "Admission note. Occupation: NIL. Abdominal pain on 1/1 morning, vomited bile content"

Transcription

1 Admission note Name: 施 OO Age: 86-year-old Gender: Female Occupation: NIL Marital status: Married Education: elementary school Date of care: 2017/1/1~1/10 BH: cm, BW: 41.3 kg, BMI: 17.64% Reason for admission: Abdominal pain on 1/1 morning, vomited bile content Present illness: The 86-year-old female patient had underlying disease of (1) arrhythmia (2) L3 compression fracture (3) Gall bladder stones s/p Cholecystectomy (4) Uterine myoma s/p hysterectomy. This time she suffered from abdominal cramping pain on 1/1 morning. Bile content vomitus was associated. The pain was aggravating while activity, and relieving while fasting. At first, she was brought to ER. Plain abdomen X ray showed dilatation of bowel loops with air-fluid level. Whole abdomen CT showed ileus and colon diverticulosis, NG tube was inserted with decompression. Then she was admitted for further treatment. Past medical history: 1. Cardiac arrhythmia under warfarin treatment 2. Denied DM & HTN 3. L3 compression fracture 4. Gall bladder stones s/p Cholecystectomy 5. Uterine myoma s/p hysterectomy Personal, Social, Occupational and family history: 1. Cigarette smoking: Denied

2 2. Alcohol consumption: Denied 3. Betel nut chewing: Denied 4. Occupation history: Denied 5. Travel history: Denied 6. Contact history: Denied 7. Family history: Asthma of father 8. Coffee or tea : tea (one cup/day) History of Allergy and Adverse Drug Reactions: NKA Family History Review of system System YES NO General Head Respiratory Cardiovascular Gastrointestinal Nausea/Vomiting: Bile content vomitus, Abdominal pain, Constipation, Body weight loss, Fever / chill, Appetite Headache, Diplopic, Blurred vision Cough, Shortness of breath, Sputum Chest pain, Tachycardia, Palpitation, Dyspnea, Orthopnea Diarrhea, Constipation, Tarry stool, Weight loss,rrectal bleeding, Tenesmus, Incontinence

3 Genitourinary Musculoskeletal Hematologic Neuropsychiatric Dysuria, Hematuria, Flank pain, Incontinence Arthralgia, Joint swelling, Limited joint range of motion, Gout, Skin rash Anemia, Gum bleeding Faint, Weakness, Dizzy, Numbness Physical examination: Vital signs: Date: ,Time:1631, BT:36.8, PR:75/min, RR:18/min, BP:165/79mmHg General appearance: ill-looking Consciousness: GCS (Glasgow Coma Scale): E4M6V5 HEENT: Eye: conjunctiva: anemic(-), sclera: icteric(-) Neck: supple, thyroid enlargement(-), lymphadenopathy(-) Chest: clear breathing sound, Heart: irregular heart beats Abdomen: Inspection: Previous s/p hysterectomy op scar, distension(-), Cullen`s sign(-), Turner sign(-) Palpation: diffuse tenderness(+), muscle guarding(-), rebounding pain(-), palpable mass(-), hepatomegaly(-), splenomegaly(-), Murphy`s sign(-) Percussion: shifting dullness(-), fluid wave(-), tympanic(+) Auscultation: silence bowel sound, bruit(-) Flank: knocking pain L(-) / R(-), pressure sore(-)

4 EXT: freely movable, pitting edema(-), Lymph node: neck(-), supraclavicle(-), axillary(-), inguinal(-) Digital Rectal examination: no palpable mass, no bloody on glove Peripheral vascular: (1)Radial a. --> Right side(++) ; Left side(++) (2)Brachial a. --> Right side(++) ; Left side(++) (3)Femoral a. --> Right side(++) ; Left side(++) (4)Popliteal a. --> Right side(++) ; Left side(++) (5)Tibial a. --> Right side(++) ; Left side(++) (6)Dorsalis pedis a. --> Right side(++) ; Left side(++) Lab: 2017/01/01( 血漿 ) PT=12.4sec(H) PT control=10.5sec INR=1.20 APTT=28.5sec APTT control=30.0sec 2017/01/01( 血液 ) Hb= 12.9g/dl(L) Ht=39.2%(L) RBC=1.41*10^6/uL(L) WBC=11.00*1000/uL Neutrophil Seg.=87.4%(H) Lymphocyte=6.9%(L) Monocyte=5.7% Eosinophil=0.0% Basophil=0.0% MCV=92.9fL MCH=30.5Pg MCHC=32.8g/dl PLT=158*1000/uL 2017/01/01( 血漿 ) Na=134mmol/L(L) K=5.0mmol/L Glucose=162mg/dL(H) BUN=135mg/dL(H) GOT=9IU/L CPK=209IU/L CPK MB=4.7ng/mL Creatinine=3.26mg/dL(H) Troponin I=<0.10ng/mL CRP= 9.6 mg/dl Image :

5 107/01/01 Plain abdomen X ray : dilatation of bowel loops with air-fluid level. 107/01/01 Whole abdomen CT: ileus and colon diverticulosis. Differential Diagnosis : Differential Reason( CC + PI Reason( CC + PI Reason( CC + PI + Diagnosis + PH + ROS ) + PH + ROS +PE) PH + ROS+PE +Image)

6 Adhesion ileus Abdominal pain, Diffuse abd 1. Abdomen X ray: bile vomitus, tenderness, dilatation of bowel Abdominal op Tympanic (+), loops with air-fluid history: silence bowel level hysterectomy, sound 2.Whole abdomen CT: ileus and colon diverticulosis. Ischemic bowel Abdominal pain Diffuse abdominal EKG: Af arrhythmia tenderness, Colon Abdominal pain Abdominal Abdomen CT: colon diverticulitis Old age, 86y/o tenderness, diverticulosis. Bowel obstruction ( ileus ) Classification: Classification Cause Mechanism ileus 1. Bowel lumen obstruction ( ex : Bezoars or tumor ) 2. Adhesion or intestine strangulation Paralytic ileus Poor bowel movement ( ex : spinal cord injury hypokalemia ) Conculsion : 1. History taking : 由病史得知病人腹痛伴隨膽汁嘔吐物, 同時過去病史有腹部手術 ( 子宮切除 ) 2. Physical examination: 身體理學檢查聽診呈現 silence bowel sound, 扣診呈現鼓音

7 3. Image 影像檢查 : 腹部 X 光 : dilatation of bowel loops with air-fluid level Whole abdomen CT: ileus and colon diverticulosis ** 綜合以上結果診斷為腸阻塞, 腸阻塞又分為 Mechanism ileus & Paralytic ileus, 因病人過去有腹部手術病史, 所以最後診斷為沾粘性腸阻塞 ( 屬於 Mechanism ileus) Care plan:( For adhesion ileus ) 1. CBC/DC CRP Bio, Electrolytes 2. NPO with NG decompression with adequate IVF supply 3. Abdominal x ray (standing) 4. Whole abdomen CT 5. Primperan 1 amp iv q8h + Dulcolax 1# sup q6h 6. Close monitor vital signs and her abdominal pain symptoms, if toxic sign is noticed ( Fever, abdominal pain aggravating, Tachycardia, Leukocytosis), arrange emergent surgical intervention for intestine strangulation possibly. 出院返家注意事項 : 1. 飲食衛教 ( 均衡飲食 充分咀嚼食物 少量多餐, 避免大塊食物吞嚥, 及避免不易, 如柿子 糯米等 ) 2. 養成良好排便習慣, 避免便秘, 自我觀察每日排氣 排便情形 3. 遵循醫師指示正確服用藥物及定時門診追蹤

Amarillo Surgical Group Doctor: Date:

Amarillo Surgical Group Doctor: Date: Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:

More information

Patient Interview Form

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

More information

Patient to complete this information

Patient to complete this information Patient to complete this information Patient s Name Birth date Today s date Referring Physician Primary Care Physician Age Occupation Retired, how long? Prior operations Medications Type Date Name Dose

More information

BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM

BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM PATIENT MEDICAL HISTORY FORM Name: Date: Social Security #: DOB: Height: Weight: Email: Primary Care Physician: Referred by: Pharmacy Name/Location/Phone Number: Dialysis Center and Phone Number (if applicable):

More information

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

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

More information

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:

More information

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more

More information

Providence Medical Group

Providence Medical Group Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance

More information

JOHN MICHAEL ROACH, MD

JOHN MICHAEL ROACH, MD GASTROENTEROLOGY JOHN MICHAEL ROACH, MD 520 N. 4 TH AVE. PASCO, WA 99301 Phone: (509) 546-8383 Name: Date of Birth: First Middle (full) Last m/d/yr Primary care provider: Referring physician: Local Pharmacy:

More information

Case 72 y/o male Past hx : 1. Ampulla of Vater cancer s/p whipple operation 2. Liver abscess with K.P. 3. GI bleeding 4. DM No drug allergy

Case 72 y/o male Past hx : 1. Ampulla of Vater cancer s/p whipple operation 2. Liver abscess with K.P. 3. GI bleeding 4. DM No drug allergy Presenter : R2 周光緯 Supervisor :VS 連楚明 Case 72 y/o male Past hx : 1. Ampulla of Vater cancer s/p whipple operation 2. Liver abscess with K.P. 3. GI bleeding 4. DM No drug allergy 2012.08.15 2/45 ER visit

More information

Patient Interview Form

Patient Interview Form Page 1 of 7 Patient Interview Form UNIVERSITY GASTROENTEROLOGY 33 Staniford Street, Providence, RI 02905 Phone 401-421-8800 Fax 401-421-2492 Patient Information First Name: MRN: Age: Last Name: Date Of

More information

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

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:

More information

Mechanical versus bioprosthetic valve. Intern: Supervisor: VS

Mechanical versus bioprosthetic valve. Intern: Supervisor: VS Mechanical versus bioprosthetic valve Intern: Supervisor: VS Patient basic data ID: N102110716 Name: Age: 64 years old Sex: male Occupation: Admission date: 0960528 Chief complaint Exertional dyspnea for

More information

ER-GS COMBINE CONFERENCE

ER-GS COMBINE CONFERENCE ER-GS COMBINE CONFERENCE 報告者 :R3 許力云指導者 :VS 連楚明 101.07.18 Patient Data 44 y/o, male E4V5M6 TPR: 37.1 /087/18 BP:141/075 mmhg SpO2: 96% 檢傷主訴 : 病患來診為腹痛 Triage: 2 History RUQ pain for 2 days Persistent and

More information

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)

More information

Patient Interview Form

Patient Interview Form Page 1 of 6 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Race Select

More information

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury

More information

Coastal Digestive Diseases, P.C. MA New Pt Ht

Coastal Digestive Diseases, P.C. MA New Pt Ht Coastal Digestive Diseases, P.C. MA New Pt Ht Interview Form Limited Use Only Estab Pt Wt Name Nickname DOB Address Occupation Social Security # Married Single Email Address: Divorced Widowed Check Contact

More information

Headache Follow-up Visit Form

Headache Follow-up Visit Form !1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:

More information

NEUROLOGICAL SURGERY, P.C.

NEUROLOGICAL SURGERY, P.C. NEUROLOGICAL SURGERY, P.C. PATIENT INFORMATION Name Date of Birth Age Address City Sate NY Zip Home ( ) - Cell ( ) - Work ( ) - Ext: Email Address _ Sex M F Soc. Sec. #: / / Single Married Widowed Separated

More information

City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,

City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,, History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden

More information

MEDICAL DATA SHEET For Patients 18 years of age and older

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

More information

725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)

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)

More information

Patient Name Date Referring M.D. Occupation Married Divorced Single Widowed

Patient Name Date Referring M.D. Occupation Married Divorced Single Widowed Patient Name Date Referring M.D. Birth date / / Age Explain your reason for the visit: Occupation Married Divorced Single Widowed Abdominal pain No yes Intensity of the pain/ Mild /moderate/ severe /10

More information

Visit ER at 10:43. Case conference. Past history. Present illlness. Physical examination. Impression

Visit ER at 10:43. Case conference. Past history. Present illlness. Physical examination. Impression Visit ER at 10:43 Case conference Supervisor: VS 吳柏衡 Presentor: R1 劉邦民 102.12.16 60 y/o male Chief complaint: syncope Triage: I T/P/R:33.2/81/18, BP=78/41mmHg, SpO2=92% Conscious: E4V5M6 Present illlness

More information

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications): Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage

More information

MARYWOOD UNIVERSITY PHYSICIAN ASSISTANT PROGRAM HISTORY, PHYSICAL, ASSESSMENT AND PLAN

MARYWOOD UNIVERSITY PHYSICIAN ASSISTANT PROGRAM HISTORY, PHYSICAL, ASSESSMENT AND PLAN MARYWOOD UNIVERSITY PHYSICIAN ASSISTANT PROGRAM HISTORY, PHYSICAL, ASSESSMENT AND PLAN PA: PRECEPTOR: MARYWOOD STAFF: PATIENT ID: AGE: SEX: DATE: Chief Complaint: History of Present Illness: 1 Medications:

More information

Please take the time to answer all questions that apply to your problem as completely as possible. Thank You.

Please take the time to answer all questions that apply to your problem as completely as possible. Thank You. USC Center for Spinal Surgery New Patient History Form Please take the time to answer all questions that apply to your problem as completely as possible. Thank You. Date Referring Doctor/Primary Doctor

More information

Patient Interview Form

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

More information

UnityPoint Clinic - Cardiology

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:

More information

Patient Intake Form for Allegany Ear, Nose, & Throat

Patient Intake Form for Allegany Ear, Nose, & Throat Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?

More information

Broward Oncology Associates, P.A. PATIENT INFORMATION

Broward Oncology Associates, P.A. PATIENT INFORMATION NAME: BIRTHDATE: AGE: LOCAL ADDRESS (Street city state zip): HOME TELEPHONE# CELL # SOCIAL SECURITY #: - - SEX MARITAL STATUS WHAT IS YOUR HT? WHAT IS YOUR WT? EMPLOYER WORK# SPOUSE'S NAME SPOUSE'S EMPLOYER

More information

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure

More information

PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.

PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand

More information

Patient Interview Form

Patient Interview Form Page 1 of 6 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

More information

Patient Name: Date of Birth:

Patient Name: Date of Birth: Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?

More information

PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION

PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care

More information

General Data. 王 X 村 78 y/o 男性

General Data. 王 X 村 78 y/o 男性 General Data 王 X 村 78 y/o 男性 Chief Complaint Vomiting twice this early morning Fever up to 38.9ºC was noted Present Illness (1) Old CVA with left side weakness for more than 10 years and with bed ridden

More information

Pain Management Questionnaire

Pain Management Questionnaire In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider

More information

*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months

*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months *542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only

More information

MEDICAL DATA SHEET For Patients 18 years of age and older

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

More information

NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C.

NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C. NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C. Past Medical History AIDS/HIV disease Anemia Asthma Bronchitis Cancer Date of last Chest X-ray Diabetes Mellitus, Type I Diabetes Mellitus,

More information

限制水分飲食需要遵循的指引 你的醫生已經要你實行限制水分飲食 有些食物算作水分 有些食物看上去不像水分, 但是仍然需要將其算作你的水分攝入量的一部分 這是因爲 :

限制水分飲食需要遵循的指引 你的醫生已經要你實行限制水分飲食 有些食物算作水分 有些食物看上去不像水分, 但是仍然需要將其算作你的水分攝入量的一部分 這是因爲 : UW MEDICINE PATIENT EDUCATION FLUID-RESTRICTED DIET CHINESE 限制飲食需要遵循的指引 本手冊給出限制飲食的基本指引 它包括一份食物清單 ( 這些食物應該算作攝入量的一部分 ), 以及幫助控制的提示 你的醫生已經要你實行限制飲食 你在 24 小時中只可以喝 毫升 (ml) 的水 即大約 盎司 (oz), 或者 杯水 繼續進行這種限制性飲食, 直到你的醫生說你可以恢復你平常所喝的水量爲止

More information

Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency

Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.

More information

New Patient Intake Form

New Patient Intake Form New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages

More information

Morris Medical Center, P.A.

Morris Medical Center, P.A. Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~

More information

Uncertainty of Measurement Application to Laboratory Medicine 鏡檢組 蔡雅雯 2014/09/09

Uncertainty of Measurement Application to Laboratory Medicine 鏡檢組 蔡雅雯 2014/09/09 Uncertainty of Measurement Application to Laboratory Medicine 鏡檢組 蔡雅雯 2014/09/09 Objectives Definitions Methodology Equation of Measurement Uncertainty Measurement Uncertainty Goal Examples Uncertainty

More information

WELCOME TO OUR OFFICE

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

More information

2. Have your symptoms affected your ability to carry out your daily activities? YES NO

2. Have your symptoms affected your ability to carry out your daily activities? YES NO QUESTIONNAIRE Page 1 of 5 Date: Referring MD (Name, Address, Phone Number): Primary Care Physician (Name and Address, Phone Number): Reason for visit: 1. How long have you had symptoms? Describe your symptoms?

More information

Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:

Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip: Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed

More information

HEART CENTER OF NORTH TEXAS, P.A. CARDIOLOGY

HEART CENTER OF NORTH TEXAS, P.A. CARDIOLOGY HEART CENTER OF NORTH TEXAS, P.A. CARDIOLOGY Dear Welcome to the Heart Center of North Texas. Your appointment has been scheduled for at with Dr. Mott. Your appointment will be at our Weatherford office

More information

Modesto Gastroenterology Medical Corporation

Modesto Gastroenterology Medical Corporation Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298

More information

Today s Date: Pt Initials: PATIENT INFORMATION. First Name: Last Name: Middle Name: Date of Birth: Social Security #: Preferred Language:

Today s Date: Pt Initials: PATIENT INFORMATION. First Name: Last Name: Middle Name: Date of Birth: Social Security #: Preferred Language: PATIENT INFORMATION First Name: Last Name: Middle Name: Suffix: Nickname: Male Female Date of Birth: Social Security #: Preferred Language: Race: Asian Native Hawaiian Other Pacific Islander Black / African

More information

Medical Case History and Examination (2) 31 years old Gender. Male Nationality. Bengali Religion. Muslim Marital Status

Medical Case History and Examination (2) 31 years old Gender. Male Nationality. Bengali Religion. Muslim Marital Status Medical Case History and Examination (2) - Demographic Data: Patient s name Suman **** CPR 86025**** Age 31 years old Gender Male Nationality Bengali Religion Muslim Marital Status Unmarried Date of Admission

More information

Alleviating Cancer Pain Toward Better Quality of Life

Alleviating Cancer Pain Toward Better Quality of Life Alleviating Cancer Pain Toward Better Quality of Life 林至芃醫師 台大醫院麻醉部疼痛科科主任台大醫院麻醉部暨腫瘤醫學部合聘主治醫師台大醫學院醫學系臨床助理教授台灣疼痛醫學會秘書長 82 y/o male Newly diagnosed PC Initial presentation Back pain Shoulder pain Rapid progressed

More information

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

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

More information

Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio

Patient Name: Date:  Address: Primary Care Physician: Online Website On TV In print On the radio 927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On

More information

CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY

CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY REGISTRATION PAGE Date: Name: Tel: 510-526-5256 (Albany) 415-334-1010 (San Francisco) Fax: 510-526-5547 christopherbrowndo@gmail.com DOB: Age: Sex: Address:

More information

Laser Vein Center Thomas Wright MD RVT Page 1 of 4

Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:

More information

Medical History Form

Medical History Form 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

More information

DATE OF BIRTH: MELANOMA INTAKE

DATE OF BIRTH: MELANOMA INTAKE MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other

More information

New Patient Medical History Form

New Patient Medical History Form New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring

More information

Case 1. Case Discussion. History. Present Illness. Impression. Physical Examination

Case 1. Case Discussion. History. Present Illness. Impression. Physical Examination Case 1 Case Discussion R1 林吉倡 2013 / 01 / 02 13-yo Male BW: 45 kg DAY1 16:35 pm C/C: Epigastric pain since this morning TPR: 36.5/94/18 BP:133/83 SpO2: 100% GCS: 15 Triage: 2 Present Illness Sudden-onset

More information

Patient Interview Form

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

More information

OUTPATIENT SUMMARY LIST. Social / Family HX. Additional Information: USE A SECOND SHEET IF NECESSARY DO NOT WRITE ON BACK OF FORM.

OUTPATIENT SUMMARY LIST. Social / Family HX. Additional Information: USE A SECOND SHEET IF NECESSARY DO NOT WRITE ON BACK OF FORM. Washington Institute of Surgery, LLC. 2311 M Street, N.W. Suite 501, Washington, DC 20037. Tel: (202) 775 9375 Fax: (202) 776 9088 Web: www.washingtoninstituteofsurgery.com OUTPATIENT SUMMARY LIST MR #:

More information

Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6

Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 These questions are general screening questions designed to identify areas where additional attention may be required. Please bring

More information

SANTA MONICA BREAST CENTER INTAKE FORM

SANTA MONICA BREAST CENTER INTAKE FORM SANTA MONICA BREAST CENTER Who referred you to see us today? Who is your primary care physician? Are there any other MDs who you would like to receive today s visit information? No Yes MD contact info

More information

Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week

Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week 3 Washington Circle W, #207/208 Patient ame: Age: Chief Complaint: Please describe what you are being seen for today: What is your hand dominance (which hand do you write with)? Left Right Ambidextrous

More information

Initial Consultation

Initial Consultation Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention

More information

Please describe, in detail, when the symptoms began:

Please describe, in detail, when the symptoms began: 161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On

More information

Inner Balance Acupuncture

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:

More information

Patient Name Date of Birth Page 1 of 6

Patient Name Date of Birth Page 1 of 6 2545 W. Hillcrest Dr. #205 Thousand Oaks, CA 91320 Admissions: 888.822.8938 Fax: 805.273.5246 Dear Medical Professional, This patient is seeking care to address eating disorder behaviors. For the patient

More information

Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)

Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #) Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency 1 2 3 4 5 6 7 8 9 10 11 12 13

More information

Jejunojejunal Intussusception Due to Intestinal Polypoid Lipomatosis: a case report

Jejunojejunal Intussusception Due to Intestinal Polypoid Lipomatosis: a case report 中華放射醫誌 Chin J Radiol 006; 31: 55-59 55 Jejunojejunal Intussusception Due to Intestinal Polypoid Lipomatosis: a case report Chia-Yang Hong 1 Wen-Sheng Tzeng Yu-Kang Chang 1 Reng-Hong Wu Chi-Chen Hou Department

More information

RHEUMATOLOGY PATIENT HISTORY FORM

RHEUMATOLOGY PATIENT HISTORY FORM !! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant

More information

NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM

NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM Today s Date: Name: Date of Birth: Race: American Indian or Alaskan Native Asian Black or African-American More

More information

PATIENT INFORMATION SHEET

PATIENT INFORMATION SHEET ALAMO NEUROSURGICAL INSTITUTE 414 W SUNSET, SUITE 205 SAN ANTONIO, TEXAS 78209 WWW.ANI-ONLINE.COM OFF: 210.564.8300 FAX: 210.564.8399 PATIENT INFORMATION SHEET Patient Name (Last, First, Mi): SSN: Street

More information

Clinical characteristics. Nutritional Management of Nephrotic syndrome 陳淑子. Causes. Medical Nutrition therapy

Clinical characteristics. Nutritional Management of Nephrotic syndrome 陳淑子. Causes. Medical Nutrition therapy Nutritional Management of Nephrotic syndrome 陳淑子 臺北醫學大學保健營養學系助理教授台灣營養學會臨床營養委員會腎臟專科小組召集人 1 Clinical characteristics Proteinuria Hypoalbuminemia Edema Hyperlipidemia Hypercoagulability Abnormal Bone metabolism

More information

SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:

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

More information

Laser Vein Center Thomas Wright MD Page 1 of 4

Laser Vein Center Thomas Wright MD Page 1 of 4 Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber

More information

New Patient Pain Evaluation

New Patient Pain Evaluation New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S

More information

Where is your pain located? Please use the diagram below to indicate where most of your pain is located.

Where is your pain located? Please use the diagram below to indicate where most of your pain is located. Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:

More information

New Pulmonary Patient Questionnaire. Name Age Date. General Medical History

New Pulmonary Patient Questionnaire. Name Age Date. General Medical History New Pulmonary Patient Questionnaire Name Age Date General Medical History 1 John S. Kim, M.D., Diplomate ABSM Lawrence A. Lynn, D.O., FCCP 1. Please list any surgeries you have had and their approximate

More information

MEDICAL QUESTIONNAIRE (male)

MEDICAL QUESTIONNAIRE (male) MEDICAL QUESTIONNAIRE (male) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501/502 Fax: 01 2780248 The appointment comprises of a discussion about this questionnaire and a subsequent

More information

PCCSS, LLP Pulmonary, Critical Care & Sleep Specialists

PCCSS, LLP Pulmonary, Critical Care & Sleep Specialists NAME: AGE: DOB: DATE: REQUESTING PHYSICIAN: NOTE: Please help us find out about you by filling out the Patient side of this form on pages 1 3. If you don t know the answer to one of the questions, ask

More information

Past Medical History. Chief Complaint: Appointment Date: Page 1

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

More information

History of Present Illness Please answer the following questions

History of Present Illness Please answer the following questions Last Name First Name Date of Birth: / / What is the main reason for your visit today? Social Security Number: History of Present Illness Please answer the following questions Bladder Cancer Urinary Tract

More information

WELCOME TO FALLS CHIROPRACTIC AND INJURY!

WELCOME TO FALLS CHIROPRACTIC AND INJURY! WELCOME TO FALLS CHIROPRACTIC AND INJURY! PATIENT INFORMATION (Most of the information below is required for insurance purposes) DATE: / / FIRST NAME: M.I.: LAST NAME: DATE OF BIRTH: / / CALLED NAME /

More information

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

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

More information

Please list any treatments you have previously had for current illness. (Physical Therapy, Surgery, Radiation, etc.)

Please list any treatments you have previously had for current illness. (Physical Therapy, Surgery, Radiation, etc.) Date: Patient Name: D.O.B Last First M.I History of Present Illness: What is the reason for your visit? Date symptom started? Please list any treatments you have previously had for current illness. (Physical

More information

Cardiovascular Genetics Clinic Arrhythmia Questionnaire

Cardiovascular Genetics Clinic Arrhythmia Questionnaire Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Primary Care Physician: Why have you been referred for a Cardiovascular Genetics Appointment? Have you had a genetics evaluation? If

More information

IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM.

IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM. Dr. Doug Scherr Date of Birth: Date: CHIEF COMPLAINT What is the main reason for your visit today? ALLERGIES Are you allergic to any of the following? Please check YES or NO for each. Check here if you

More information

Creve Coeur Family Medicine, LLC

Creve Coeur Family Medicine, LLC Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal

More information

Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency.

Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency. GENERAL SURGICAL ASSOCIATES A practice of Lehigh Valley Physician Group Suite 208 ~ 1240 S. Cedar Crest Boulevard ~ Allentown, PA 18103 Phone: (610) 402-9780 PLEASE COMPLETE THIS FORM PRIOR TO YOUR VISIST

More information

Past Surgical History

Past Surgical History Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression

More information

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

PULMONARY MEDICINE PATIENT QUESTIONNAIRE PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical

More information

CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)

CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425) IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:

More information

Name: Date of Birth: Age: Address: City State Zip

Name: Date of Birth: Age: Address: City State Zip Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us?

More information

The epidemiology of patients with dizziness in an emergency department

The epidemiology of patients with dizziness in an emergency department Hong Kong Journal of Emergency Medicine The epidemiology of patients with dizziness in an emergency department 急症室頭暈病者的流行病學 JMY Lam 林美怡, WS Siu 蕭詠詩, TS Lam 林子森, NK Cheung 張乃光, CA Graham 簡家廉, TH Rainer

More information