Name: Date of Birth: Neurology New Patient Form
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1 Neurology New Patient Form Date: Primary Care Physician: Medical History: Please circle any health condition that applies to you and specify/comment if needed. If you have any questions, please ask a member of our staff for assistance. Thank you. Medical History (For, Please Specify) Alcohol/Drug Problem Breast Lump, breast problem Cardiac Cardiomyopathy, Congestive Heart Failure, Endocarditis, Heart attack, Heart Disease, High blood pressure, High cholesterol, Pacemaker, Valve problem, Cancer Brain, Breast, Cervical, Colon, Lung, Parathyroid, Ovarian, Prostate, Rectal, Skin, Stomach, Throat, Thyroid, Uterine, Digestive/Stomach Barrett s Esophagus, GERD, Hernia, Intestinal problem, Liver Disease, Ulcer, Endocrine Diabetes, Thyroid Disease, Goiter, Hematology Anemia, Bleeding disorder, Clotting disorder, Immune Disorder AIDS, HIV, Lupus, Kidney Disease, Kidney stone, kidney problem Musculoskeletal Arthritis/Joint problem, Hernia, Osteoporosis/Osteopenia, Neurological Nerve Disease, Stroke, Psychiatric Anxiety, Depression, Insomnia, Sleep walking, Respiratory Asthma, Bronchitis, COPD,, Chronic lung disease, Emphysema, Obstructive sleep apnea, Pneumonia, Skin Eczema, Psoriasis, Urinary / Reproductive Abnormal pap test, Bladder problem, Menstrual abnormality, Prostate problem, Sexually transmitted infection, Vascular (Arteries, veins): Aneurysm, Medical History: Gout, Injury, Lyme, Hepatitis A / B / C, Tuberculosis, Scarlet fever, Ulcer, other Specify/Comments
2 Medication: Please list all medications with dose and frequency. (Please include non-prescription medications, vitamins, and supplements) Medication Dose Frequency (i.e., how many times daily?) Prescribed By Pharmacy: Where would you like us to send your prescriptions? Local pharmacy name, location: Mail order pharmacy name: Do you take any of the following blood Thinners? (Circle any that apply): Aspirin, Ibuprofen-based products (Ex. Motrin, Advil), Coumadin, Lovenox, Plavix, Xarelto, Pradaxa Do you need any medication refills today? If so please list: Allergies: Please list ALL medication, food, and/or environmental allergies, and specify reaction type that occurs (i.e. rash, itching). Have you ever had an anaphylactic reaction (severe, near deadly reaction)?: (Circle) Yes / No Family History: Please note any serious family medical history Father: Mother: Brother: Sister: Family History: Father s Father: Father s Mother: Mother s Father: Mother s Mother: Social History: Please circle the following that apply to you: Are you: Single Married Divorced Are you sexually active? Yes No What is your employment/occupation? Please outline your use of the following products, past or present: Product Current Use? Daily Amount Weekly Amount Past Use? Tobacco What did you use to smoke? cigarettes, pipe, cigars, chewing tobacco Alcohol Recreational Drugs Caffeine Do you use other forms of nicotine products? (circle) smokeless tobacco, electronic cigarettes?
3 Immunization: Immunization up to date? When? Flu Vaccine this year? Pneumonia Tetanus Pertussis Zostavax History of Blood Transfusion? Do you have a Living Will/Advance Directive? Past Surgical History/Past Procedures: Recent Hospitalization(s): Current and/or Previous Medical Specialists: (Name/Specialty) Recent Diagnostic Studies: (within the last 3 years) 1. Heart Testing (Type / Where / When) 2. Lung Testing (Type / Where / When) 3. X-Ray (Where / When / Specify Body Part) 4. Ultrasound (Where / When / Specify Body Part) 5. CT (Where / When / Specify Body Part) 6. MRI (Where / When / Specify Body Part) 7. Biopsy (Where / When / Specify Body Part) 8. (Type / Where / When) 9. Most Recent Blood Testing/Labs (Where / When) Health Maintenance: Please note the most recent date you received any of the below health services. Service Date (Month/Year) Physician Yearly Physical Eye Exam (If Dilated Eye Exam, please specify) Dental Exam Pap Smear Prostate Exam Mammogram Colonoscopy Diabetic Foot Exam
4 Review of Systems: (Please circle symptoms that are currently present) General Symptoms: fever, night sweats, fatigue, weight change, change in appetite Head, Eye, Ear, Nose, Throat: ringing of the ears, vertigo, voice changes, decreased hearing Skin: rash, itching, changes in moles Respiratory: Cough, shortness of breath Cardiovascular: chest pain, rapid heartbeat, palpitiations, irregular heartbeat, swelling in limbs, shortness of breath with activity, hypertension, low blood pressure Gastrointestinal: Nausea, vomiting, constipation, diarrhea Genitourinary: Urinary retention, urgency Musculoskeletal / Neck: muscle aches, cramping, joint swelling, joint pain, recent trauma Neurological: stroke, numbness, weakness, fainting, difficulty walking, speaking, concentrating or remembering, headaches, seizures, tingling, dizziness, loss of consciousness, neck pain, trouble swallowing, tremor Hematology: abnormal bleeding, easy bruising, anemia Endocrine: Diabetes, thyroid disorder : Reason(s) for visit today: Do you have any question(s) for the provider? Do you need any medication refills today? If so please list: Signature of patient or guardian Printed name of patient or guardian Date
5 Headache History (Please complete 1-21 below if you are seeing Neurology for headaches) Do you have more than one headache type? Yes No If yes, please use one history sheet for each. 1. Onset of first headache Headaches started years ago. I was: younger than over 50 years old 2. Precipitating event (trigger of first headache): None known Injury Menarche (first period) Pregnancy : 3. Frequency: They occur: times each day week month Are they increasing? yes no They are more frequent on: Weekdays Weekends Vacation Spring Summer Fall No Relation Winter 4. Onset of each headache: Gradual Sudden Varies Onset most frequent: Morning Afternoon Evening Night 5. Duration: Lasts: hours days with medication hours days without medication 6. Free of headache from: to Never free If never free, when was the last time you went 24 hours without a headache? 7. Intensity: With medication: Mild Moderate Severe Incapacitating Without medication Mild Moderate Severe Incapacitating 8. Headaches effect on ability to function: With medication Able to function normally Ability to function slightly decreased Ability to function severely decreased Totally bedridden Without medication Able to function normally Ability to function slightly decreased Ability to function severely decreased Totally bedridden 9. Location: b=beginning of headache; c=continuation of headache (circle all that apply) b c left side; b c right side; b c either side; b c both sides: b c behind eye(s); b c neck/back of head; other: 10. Pain type: Throbbing Achy Pressure Stabbing Shooting Tight Dull Burning Searing :
6 11. Hormonal: Your headaches are affected by: your menstrual cycle pregnancy How? 12. Headaches can be brought on by: Foods Fatigue Physical exertion Stress Weather Changes Hunger Lack of sleep Menstruation Loud sounds High altitude Alcohol Too much sleep Coughing Bright lights Odors Medications Sex/orgasm Chewing or talking Neck pain : 13. Warnings that a headache is coming: Light Flashes Numbness Upset Stomach Zigzag lines Dizziness Weakness Blindness Lightheadedness : 14. Associated symptoms: Nausea/vomiting One eye tears Sore or stiff neck Ringing in ears Diarrhea Change in sexual interest Both eyes tear Lightheaded/dizzy Increased urination Numbness/tingling Concentration/memory Constipation Fatigue or weakness Increased appetite Blurred vision Runny or stuffy nose Insomnia Decreased appetite Double vision Anxiety, tension or irritability : Sensitive to: light sounds odors 15. During a headache, you are more comfortable: When lying down With massage or pressure on scalp When pacing In a dark, quiet room With HOT or COLD compress Chewing or talking 16. Previous testing (Please give date & results): MRI: Cervical spine films: CAT scan: Sinus X-rays: EEG: MRA/MRV: : 17. Previous evaluations (Please give name, date & results) Neurologist: Headache specialist: Internist: Ear, nose & throat specialist: Dental evaluation: Eye exam: Psychological testing:
7 18. Previous non-medical treatments & evaluations Biofeedback/relaxation/self-hypnosis Physical therapy Chiropractor Nutritional counseling Acupuncture/acupressure Allergy testing : 19. Are you currently taking medication or have you previous taken medication for headache? Yes No (IF YES, PLESE COMPLETE MEDICATION HISTORY) 20. With current medication, how quickly do you feel adequate relief? Within 2 hours In more than 2 hours Relief is never adequate Not currently taking medication 21. Please circle all previous headache medications and indicate next to the drug name: add H for helpful (long or short term) add U for not helpful. Prophalactics Antidepressents Amitriptyline Nortriptyline Effexor Cymbalta Anticonvulsants Neurontin (gabapentin) Depakote Topamax (topiramate) Keppra Zonagram Lamictal Lyrica Vimpat Antihypertensives Inderal Timorol Varapamil Lisinopril Labatalol Antipsychotics Zyprexia Seroquel Geodon Risperdal Thorazine Compazine Botox Aricept Mixilitine Lithium Abortives Triptans Amerge Axert Frova Sumatriptan indicate tab or inject Maxalt Relpax Zomig Combinations Fiorinal Fioricet Midrin OTC ex NSAIDs Aspirin Tylenol Excedrin Ergots DHE: Antinausea Compazine Reglan Norflex Clonapin injection; nasal spray NSAIDS Celebrex Mobic Naproxen Ibuprofen Relafen Toradol Narcotics Stadol Oxycodone Oxycontin Ultram Neucentya Zanaflex Soma Ativan Anti-anxiety Valium Muscle relaxants Skelaxin Flexeril
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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
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
Health History. Tests and Procedures: Test: Date: Location: Provider: Abnormal: Results/Notes: Monthly self breast exam. Last mammogram (female)
Comprehensive Cancer Center A Cancer Center Designated by the National Cancer Institute Please answer the following questions and bring this form to your first appointment at Rutgers Cancer Institute of
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:
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES 13414 Medical Complex Drive, Suite 6 Tomball, TX 77375 281-516-0212 Welcome! We are glad that you have chosen Tomball Regional Internal Medicine Associates
FAMILY MEDICINE New Patient Medical History Form
FAMILY MEDICINE New Patient Medical History Form Personal History : Name: Date of Birth / / (mm/dd/yyyy) Age Occupation Birthplace (City&Country) Marital Status (check one): Single Married Divorced Separated
Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:
Patient Information Patient Name:,, Last First middle initial Address: Phones:,, Home Work Cell Sex: Female Male E-Mail: Date of Birth: / / Mo. Day Year Primary Physician: Marital Status: Single Married
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
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:
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
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):
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
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
NEW PATIENT INTAKE FORM
WILLIAM S. CRAWFORD, MD NEW PATIENT INTAKE FORM Patient Name: DOB: INSTRUCTIONS: Please complete the following questionnaire before you see the doctor. Answer each question in as much detail as possible.
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.