Retinal Consultants Medical Group Electronic Health Record Update/Actualizacion de Historia Clinica Electronica
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1 Rev. 01/2014 Page 1 of 5 Retinal Consultants Medical Group Electronic Health Record Update/Actualizacion de Historia Clinica Electronica DEMOGRAPHICS/DEMOGRAFIA: Name: Nombre: Retina Physician: Doctor: Chang Equi Patel Pearlman Reed Telander Tsai Wendel Date of birth: Fecha de nacimiento Office: Oficina: Race/Raza: (Circle one/circule uno) American Indian or Alaska native Indioamericano o Native de Alaska Native Hawaiian or Pacific Islander Nativo Hawaiiano o de isla Pacifica Asian Asiatica White Blanco Black or African American Africano Americano Other Race Otra raza More than one race Más de una raza Choose not to answer Prefiere no contestar Hispanic or Latino Hispano o Latino Language preference/preferencia de lenguaje: (circle one/circule uno) English/Inglés Spanish/Español Russian/Ruso Other/Otro FAMILY HISTORY/HISTORIA FAMILIA: Does anyone in your family (related to you) have: Alguna persona de su familia tiene: Blindness/Ceguera: NO YES/SI If yes, Who? Retinal disease /enfermedad retinal: NO YES/SI If yes, Who? Glaucoma: NO YES/SI If yes, Who?
2 Rev. 01/2014 Page 2 of 5 SOCIAL HISTORY/HISTORIA SOCIAL: (mark the appropriate check box and/ or fill in the blanks/circule o llene la linea) SMOKING FUMAR: ALCOHOL: OCCUPATION/ OCUPACIÓN: I don t smoke and have never smoked Yo no fumo y nunca e fumado I am a former smoker and smoked for years Antes fumaba y fume por años I smoke and smoke packs per day Fumo y fumo paquetes por día I don t drink any alcohol Yo no tomo alcohol I occasionally drink alcohol Ocasionalmente tomo alcohol Retired/ Retiradora PAST MEDICAL HISTORY/HISTORIA ANTERIOR MÉDICA: Medical Problems/Problemas Médicos: I have NO previous medical problems/ Yo nunca e tenido ninguno de estos problemas medicos. Please indicate if you have PREVIOUSLY had any of the following conditions: Por favor indicar si usted previamente tuvo alguna de las siguientes condiciónes: Retinal surgery - (please explain on next page) Cirugía de retina - (por favor, explique en la página siguiente) Cataracts/ cataratas Other eye surgeries (please provide details on next page i.e. cataracts, laser) Otro cirugía de ojos (por favor describa el tipo de cirugía ) Epilepsy (seizures) Epilepsia (convulsiones) Strokes Accidente cerebrovascular High blood pressure Presión arterial alta High cholesterol Cholesterol alto Heart murmur Sopio cardiaco Irregular Heart Rhythm Ritmo cardiac irregular Angina/Chest Pain Dolor de pecho Heart problems Problemas cardiacos Asthma/asma Pneumonia/Neumonia Pulmonary embolism Embolia pulmunar Tuberculosis Emphysema/enfisema Thyroid Issues (list type) Problemas de tiroides y cual Goiter/Bocio Jaundice/Ictericia Anemia Hepatitis Stomach or peptic ulcer Ulcera estomacal o peptica Colitis Rheumatic fever Fiebre rheumatica Kidney disease Enfermedad renal Kidney stones Calculos renales Cancer (type)
3 Rev. 01/2014 Page 3 of 5 Diabetes: diagnosed in Require Insulin Most recent A1C: Diabetes: diagnosticado en Requierre insulin. Más reciente A1C Please indicate if you have any of the following problems within the last month: Por favor indicar si usted tuvo alguno de los siguientes problemas dentro de el mes pasado I have not experienced any of these symptoms in the last month. Yo no e tenido ninguno de estos sintomas en el mes pasado GENERAL Recent unexplained weight gain;how much Aumento de peso inexplicable; cuanto Recent unexplained weight loss: how much Perdida de peso inexplicable; cuanto Fatigue/fatiga Weakness/Debilidad Fever/Fiebre Night sweats/sudar de noche MUSCLE/JOINTS/BONES MUSCULOS/ARTICULACIONES/ HUESOS Numbness/Entumecimiento Joint pain/dolor de articulaciones Muscle weakness Debilidad muscular Joint swelling: Where? Hinchazon de articulaciones, donde: KIDNEY/URINE/BLADDER RIÑÓN/ORINA/VEJIGA Frequent or painful urination Orinar frequentemente o con dolor Blood in urine Sangre en la orina NERVOUS SYSTEM/ SISTEMA NERVIOSO Headaches dolor de cabeza Dizziness/Mareo Fainting or loss of consciousness Desmayo o perdida de Numbness or tingling Entumecimiento o hormigueo Memory loss Perdida de memoria EARS/OIDOS Ringing in ears Zumbido en los oidos Loss of hearing Perdida de audicion PSYCHIATRIC/ PSIQUIÁTRICO Depression/deprecion Excessive worries/ Preocupaciones excesivas SKIN/PIEL Redness/enrojecimiento Rash/Ronchas Nodules/bumps/nodulos Hair loss /Perdida de pelo BLOOD/SANGRE Anemia Clots/Coagulos HEART AND LUNGS/ CORAZON Y PULMONES Chest pain/dolor de peso Palpitations/palpitaciones Shortness of breath/falta de aliento Fainting/Desmayo Swollen legs or feet piernas o pies hinchados Cough/tos STOMACH AND INTESTINES/ ESTÓMAGO Y LOS INTESTINOS Nausea Blood in stools Heartburn/acidos Sangre in las heces Black stools Heces negras
4 Rev. 01/2014 Page 4 of 5 If you have answered YES to any of the questions above and on the previous page, please provide details below. If you need more space, please attach your additional comments to this document. Si usted contest sí a alguna de las preguntas de arriba y en la pagína anterior, per favor, pong alas detalles abajo si necesita más espacio, por favor adjunte sus comentarios adicionales a este documento. ALLERGIES/ALERGIAS: Please list your current ALLERGIES to any medications and reactions Por favor listé sus alergias a cualquier medicamento y reacciones I have no known medication allergies/no tengo allerias a las medicaciones Allergen/Alergeno Reaction/Reacción (i.e. rash)
5 Rev. 01/2014 Page 5 of 5 Name/: Nombre DOB: Fecha de nacimiento PATIENT MEDICATION LIST MEDICATIONS/MEDICACIONES: I am not currently taking any medications/no estoy usando ningun medicamento. I am on a medication regimen. (Please complete the attached medication list form). Estoy en un regimen de medicamentos (por favor completé la forma adjunta de la lista de mdicaciones Please list for us any medications you are taking including dietary/nutritional supplements, vitamins, minerals, over the counter, and herbal medications. Medication Name Nombre de medicacion Dose Dosis Route (i.e. orally, injection, patch) Routa Frequency (i.e. once a day, twice a day, etc.) Frequencia (una día, dos al día)
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Name of Recipient: Recipient s DOB (if known) Relationship to Recipient: (Example: mother, father, sister, brother, friend, etc)
The Christ Hospital Health Network DONOR REGISTRATION INFORMATION Phone: 513-585-2493 Fax: 513-585-0433 (Please be advised donor information is needed ONLY to register donor in the Christ Hospital system.
Name of Pa. tient: Last. First. per day) 50 mg. X-ray dye or. IV contract. Name (Last) (First) Address. City, state/ zip code
Division of Cardiology for the Academic Medical Center of the University of Texas Medical School at Houston NEW PATIENT HISTORY FORM Please complete and fax to 713-512-2245 Name of Pa tient: Last _ First
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
Patient Health History
Patient Health History This information is very important in your care. Please complete as carefully and accurately as possible. Name: Date: Height: inches Weight: lbs Age: Symptoms: 1. Type of symptoms
Gender: Male Female Age: Current Address: City: State: Zip Code: Work Phone: Is it okay to leave a message? VISIT INFORMATION
SIENA PROACTIVE INTERNAL MEDICINE DR. DEBORAH BLENNER 45 Terry Road, Suite B Smithtown, NY 11787 www.sienaproactive.com Phone: (631) 656-8171 Fax: (631) 656-8173 PATIENT INFORMATION Last Name: First Name:
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:
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
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
Registration and History Form
Registration and History Form PATIENT INFORMATION Date: / / Patient Address City State Zip Sex M F Age Birthdate Occupation _ Employer Spouse s Name _ Sex M F Age Birthdate Occupation Spouse s Employer
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Last Name: First Name: Date Form Completed: Referring Physician: Address: City: Sex: Marital Status: Race: Age: Married Caucasian Single Male Divorced African American Hispanic
I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
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
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
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
Referring Physician/Therapist. Primary Care Physician. Reason for Visit
Name Age Date Referring Physician/Therapist Primary Care Physician Reason for Visit If you are having pain, use the diagram and symbols to indicate where it is. Ache: AAA Burning:XXX Numbness:OOO Pins/Needles: