Medications: Prescription and Non-prescription medications, vitamins, home remedies, birth control pills, herbs.
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- Abner Sparks
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1 Medical History PLEASE COMPLETE ALL PAGES Name: Date: DOB: Please be as specific as possible as this form will give us a better understanding of your medical concerns and conditions. If you are uncomfortable with any questions, do not answer them. Please contact family members if you need assistance in completing the Family History section. You may attach additional pages as necessary. THANK YOU! How would you rate your current health? Excellent Good Fair Poor Current age: Weight: Height: Ethnicity: Waist Measurement: Date of Last Physician Exam: Medications: Prescription and Non-prescription medications, vitamins, home remedies, birth control pills, herbs. Medication: Dose (eg. Mg/pill) How many times/day When Started Why Using
2 Allergies or Adverse Reactions to Medicines: Date of most recent screening for the following: Cholesterol Chest X-Ray EKG Spirometry Bone Density Any other VASCULAR TEST Personal Medical History: Please indicate whether you have had any of the following medical problems (with dates): Heart Disease Bleeding/Clotting Problems Alcoholism specify type Rheumatoid Arthritis Gout Aortic Aneurysm High Blood Pressure Blood Transfusion Polycystic Ovaries High Cholesterol Poor Blood Flow to Extremities Cancer (Malignancy) Diabetes specify type Thyroid Problems Depression / Suicide Attempts Unexplained Nerve Problems specific types Lupus Psoriasis Migraine Headaches With Aura Without Aura Fatty Liver Pre-diabetes Chronic Dental Problems Osteoporosis Autoimmune Disorder H. Pylori Infection Other
3 Have you ever had the following procedures? If so, please list the dates: Coronary Artery Bypass Surgery Angioplasty or Stent Angiogram Have you ever been hospitalized for illness? Yes No If so, list when and reason: Surgical History: Please list all other operations (with dates) Social History: Tobacco use: Cigarettes Never Quit: Date: Pack/Years Current Smoker: Pack/ day Other Tobacco Pipe Cigar Chew # of years Are you interested in quitting? No Yes Second-hand smoke exposure? No Yes Alcohol use: Do you drink alcohol No Yes # of drinks/week Is alcohol a concern for you or others? No Yes Sexual History: Male do you have a problems with erections? No Yes Date of Onset: Female: Birth Control Method: None Needed #of pregnancies #of deliveries #of miscarriages Problems with pregnancy or deliveries? Osteoporosis Osteopenia Any history of gestational diabetes? No Yes Eclampsia? No Yes Children: Weighing Over 10 lbs. at birth? No Yes 1st day of most recent period: Age at 1st period: Frequency: Length of each:
4 Other Concerns Caffeine Intake: None Coffee/Tea cups/day Sodas day Chocolate oz/day Weight: Are you satisfied with your weight? No Yes Diet: How do you rate your diet? Good Fair Poor Do you take supplements? No Yes(if so, what kind?) Do you drink 4 large glasses of milk daily or take calcium supplements? No Yes Exercise Do you exercise regularly? No Yes What kind of exercise? How long? Minutes? How often? If you don t exercise, why? Socioeconomics: Occupation: Employee: Years of Education/Highest Degree: Marital Status S M D W Spouse/partner s name: Who lives at home with you? Number of Children: Ages: How would you classify the stress at work? Minimal Medium High How would classify the stress at home? Minimal Medium High Do you feel anxious, angry, irritated or rushed? No Yes
5 Nutrition: How many daily servings of the following do you have? Whole grains Fruits Vegetables How many times in one week do you consume the following items? Eggs Fish Chicken/Turkey Red Meat Butter Margarine Other high fat dairy products Other low fat dairy products Fried Foods High fat snacks What type of cooking oil do you use? Review of Symptoms: Please Check ( ) any current problems you have on the list below: Constitutional : Fever/Chills/Sweats Change in skin texture Change in hair texture Unexplained weight loss/gain Inability to stand heat Change in energy / weakness Brittle nails Inability to stand cold Excessive thirst or urination Dry skin Respiratory: Cough/Wheeze Difficulty Breathing Snoring Eyes: Change in vision Ears/Nose/Throat/Mouth: Difficulty hearing/ringing in ears Problems with teeth/gums Hay fever / Allergies Growth in throat / neck Cardiovascular: Chest pain / discomfort Palpitations Chest:(Breast) Breast lump / nipple discharge Skin: Rash/mole change Acanthosis nigricans Geuitonrinary: Unusual frequency of urination
6 Sexual: Problems with erectile function Gastrointestinal: Abdominal pain Diarrhea / constipation Blood in bowel movement Heartburn Nausea/Vomiting Neurological: Headaches Loss of coordination Light-headedness Tingling/Pain/Numbness in hand or feed Memory loss Psychiatric: Problems with sleep Depression Panic attacks Mania Blood/Lymphatic: Easy bruising/bleeding Unexplained lumps Any other symptoms? If yes, please explain:
7 Family History Please indicate the current status of your immediate family members: Alive Deceased Age (present or at death) Comments/Cause of death Mother s Mother Mother s Father Father s Mother Father s Father Father Mother Sister Sister Sister Brother Brother Brother Daughter Daughter Daughter Son Son Son Please use this space to add any additional family members:
8 Family History Please indicate with a (check) family members who have had any of the following: Medical Condition Mom Dad Sis. Bro. Dghtr Son Mom s Mom Alcoholism Anemia Aortic Aneurysm Alzheimer s Arthritis Asthma Autoimmune disorder Bleeding problems Carotid artery disease Carotid artery disease Cancer Gout Heart attack Depression Diabetes-Type 1 (Childhood Onset) Diabetes-Type 2 (Adult Onset) Other genetic disease High Cholesterol (hyperlipidemia) High blood pressure (hypertension) Immunosuppressive disorders Kidney disease Osteoporosis Peripheral vascular disease Epilepsy (seizure disorder) Stroke Substance Abuse Thyroid disorder Smoking Sleep Apnea Mom s Dad Dad s Mom Dad s Dad Mom s Sis Mom s Bro Dad s Sis Dad s Bro
9 Demographics Form Please Print Name: Male Female First Middle Last Address: City: State: Zip: D.O.B: / / Age: Social Security#: - - Marital Status: S M D W circle Home Phone: ( ) Address: Cell Phone: ( ) Other Phone: ( ) Employer Work Phone: ( ) Emergency Contact (Friend / Relative): Phone: ( ) Parent / Spouse Name: First Middle Last Insurance Co.: ID#: Group#: Subscriber s Name: Subscriber s Date of Birth: / / Person responsible for the bill?: Self Spouse Other Name (if different from above): How did you hear about our center? Patient s Signature: Date:
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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
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
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?
New Patient Questionnaire
New Patient Questionnaire Welcome to Mass General/North Shore Cardiology. Please fill out the following questionnaire, answering each question to the best of your ability. The information will assist your
Adult Health History New Patient
Adult Health History New Patient Today s Date PREFERRED NAME DATE OF BIRTH Reason for visit: What are your health goals for the next year? Previous Primary care Provider? Last visit? Specialists (Past
Initial Patient Intake Form
Initial Patient Intake Form Patient Registration Today s Date Patient Name (last) (first) (middle) Address (city) (state) (zip) Date of birth (mm/dd/yyyy) SSN # Current Gender Identity: Male Female Transgender
Cell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should