B) If any item or statement on this form applies to you, please check the square corresponding to that item or statement.
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1 PATIENT INSTRUCTIONS FOR COMPLETING THE : A) This detailed questionnaire of your health history is extremely important. Your past health experiences play a major role in developing a successful treatment program for your headaches. Please take the time to fill out and complete this form to the best of your ability. B) If any item or statement on this form applies to you, please check the square corresponding to that item or statement. C) Those items or statements which do not apply to you are to be left blank. D) Example #1 - Under: Past Medical History Cardiovascular Past Present Hypertension Check the corresponding square only if you have had or have Hypertension; OTHERWISE LEAVE BLANK. Example #2 - Under: Social History Daily caffeine consumption Never Moderate Occasional Excessive Check the corresponding square which applies to you. Example#3 - Under: Severity of Headache Mild Moderate Severe Incapacitating Only Check the square which applies to you. E) On designated pages of the questionnaire you are asked to write additional information. There is space provided for any further descriptive information you may feel is important or may be helpful. F) Please do not write the additional information on those pages of the questionnaire where you are asked to only check the squares corresponding to a particular item or statement. G) All the information obtained on the Patient Health/History Questionnaire will be evaluated at the time of consultation. Page 1 of 1
2 Baylor All Saints Medical Center Headache Center 1400 Eighth Avenue Fort Worth, TX Name: Age: Marital Status: Place of Residence: Date/Place of Birth: Spouse's Occupation: Referred by Dr: Referring Dr. Phone #: Your Occupation: Referring Dr. Address: Please list the name of any other neurologist(s) or headache specialist(s) consulted for headaches: CHIEF COMPLAINT: Please write a concise statement describing the neurological condition/symptom/or diagnosis; the reason for neurological consultation: HISTORY OF PRESENT ILLNESS: Please write a brief chronological description of your neurological condition (the above chief complaint): Page 1 of 11
3 HEADACHE HISTORY The Headaches Began: In childhood Between In teens Between Over 50 years old Cause of Headaches at Onset: No known cause Accident or injury Stress Precipitating Factors: Stress/tension Anxiety Fatigue Certain foods Alcohol Perfumes Exertion/activity Exertion/activity Coughing/sneezing Certain medications Weather changes Positional change Menstruation Frequency of Headaches: Daily For months Weekly For months Monthly For months Few times a year Severity of Headaches: Mild Moderate For years For years For years Severe Incapacitating Activity Level During a Headache: Can continue normal activities Normal activities are impaired Must stop activity and rest awhile Must go to bed Totally incapacitated Headache Reaches Maximum Intensity in: Seconds Hours Minutes Days Hormonal (women): The headaches are associated with the menstrual cycle The headaches are associated with birth control therapy The headaches are associated with any hormone therapy The headaches worsened with pregnancy The headaches improved with pregnancy The headaches started in menopause Warnings (Prodrome) Before Headache Starts: Craving for sweets Personality change Upset stomach Depression Nausea Hyperactivity Diarrhea Muscle aching Dizziness Visual disturbance Sleep: Insomnia Sleep takes away the headache Sleep disorder Snoring Duration of Headache: Lasts seconds without treatment Lasts minutes without treatment Lasts hours without treatment Lasts days without treatment Lasts 1-2 hours with immediate treatment Lasts 2-4 hours with immediate treatment Lasts 4-24 hours with immediate treatment Lasts days with treatment Page 2 of 11
4 HEADACHE HISTORY (Continued) Family History of Headache: Mother's side (maternal) Father's side (paternal) Brothers Sisters Children Location of Headache: On the left side of head On the right side of head Over left eye Over right eye Over both eyes Over whole head Symptoms of the Headache: Pain lasts between 4-72 hours Pain is throbbing or pounding Pain is worse on just one side of the head Pain inhibits daily activity Nausea may occur with the headache Vomiting may occur with the headache Intolerance to light (photophobia) Intolerance to noise or sounds (phonophobia) Visual changes occur before headache Blurred vision Loss of half of vision Loss of vision in one eye White or colored geometric figures (photopsias) Spots or sparks Flashes of light Streaks of light/wavy lines Shimmering geometric designs (fortification scotoma) Honeycomb patterns Crescent shaped Horseshoe shaped Numbness/tingling in arms or legs Numbness/tingling in trunk Numbness/tingling in face Paralysis of arm or leg Inability to properly use an arm or leg Sudden acute, severe, excruciating, debilitating headache The excruciating pain starts in minutes The pain is immediately debilitating The pain is in one eye The eye becomes red The eye starts to tear The eyelid droops There is sudden nasal congestion There is sudden nasal discharge The attacks occur daily The attacks occur several times a day The attacks occur every other day The headache is of mild to moderate intensity The headache does not prohibit daily activity The headache may last up to seven days The headache is without nausea The headache is without vomiting The headache is without intolerance to light The headache is without intolerance to noise/ sound The headache is like a vise around the head The headache is in a hat band distribution The headache is over the whole head The headache is not aggravated by physical activity Effects of the Headache: Daily activities have changed The headaches affect work performance Social activities are limited The headaches have caused marital problems The headaches have led to depression The headaches have led to seeing a psychiatrist The headaches have led to seeing a counselor Page 3 of 11
5 MEDICATIONS Past Present Past Present Migraine Specific Medications: Imitrex tablet Imitrex nasal spray Imitrex injection Maxalt Zomig Amerge Axert Frova Relpax Treximet Cafergot tablets Cafergot suppository Migranal nasal spray DHE-45 Prescription Pain Medications: Butalbital Fioricet Fiorinal Esgic Fiorinal w/ codeine Phrenilin Hydrocodone Lorcet Lortab Vicodin Norco Vicoprofen Darvon Darvocet Oxycodone Nonsteroidal Anti-Inflammatory Medications: Ibuprofen Advil Motrin Nuprin Naproxen Aleve Naprosyn Naprelan Vioxx Celebrex Bextra Combination Medications: Anacin Excedrin Midol Aspirin Containing Medications: Aspirin Bufferin Ecotrin Alka Seltzer Sinus meds Acetaminophen Containing Medications: Tylenol Other aspirin free pain meds OxyContin OxyIR Percocet Percodan Roxicodone Tylox Stadol nasal spray Ultram Tylenol No.3 or No. 4 Page 4 of 11
6 TEST / X-RAYS Test Year Performed Head CT Past 5 years Head MRI Past 5 years Cervical CT Past 5 years Cervical MRI Past 5 years EEG Past 5 years Spinal Tap Past 5 years Head MR Angiogram Past 5 years Head CT Angiogram Past 5 years Blood Tests Past 5 years PLEASE FILL IN THE BOX FOR ANY LISTED MEDICATION EVER USED FOR HEADACHES: Ambien Amitriptyline Anaprox Alprazolam Anaprox DS Apresoline Atenolol Ativan Bellergal-S Bextra Botox BuSpar Butalbital Cafergot tablets Cafergot suppositories Cataflam Celebrex Celexa Clinoril Codeine Dalmane Darvon Darvon Compound Darvocet-N 100 Deltasone Demerol Depakote Desyrel Desipramine D.H.E.-45 Diazepam Dilaudid Dilantin Dolobid Doxepin Duract Effexor Elavil Endep Ergotamine Ergomar Ergostat Esgic Fioricet Fiorinal Fiorinal w/codeine Fiorpap Gabitril Haldol Hydrocodone Imipramine Inderal Indomethacin Indocin Indocin SR Indochron E-R Indomethacin SR Isocom Isopap Isometheptene/ dichloralphenazone/ acetaminophen Ketoprofen Klonopin Lamictal Lexapro Lithium Lorazepam Lorcet Lorcet Plus Lorcet HD Lortab Lortab ASA Lyrica Meclomen Medrol Dosepak Methadone Midrin Mobic Morphine Naprelan Napron X Naprosyn Naproxen EC-Naprosyn Neurontin Nifedipine Norco Norpramin Orudis Oruvail Pamelor Paxil Percocet Percodan Periactin Phrenilin Prednisone Procardia Propranolol Prozac Relafen Restoril Sansert Serzone Sinequan Stadol Stadol NS Talwin Thorazine Tofranil Tolectin Topamax Tranxene Trazodone Triavil Tylenol No.3 Tylenol No.4 Tylox Ultram Wellbutrin Valium Valproic acid Vioxx Verapamil Vicodin Vicodin ES Wigraine Xanax Xylocaine Zoloft Zonegran Zanaflex Page 5 of 11
7 PAST MEDICAL HISTORY Past Present Past Present EYES/EARS/NOSE/THROAT Blindness Double Vision Cataracts Injury to Eye Glaucoma Iritis Keratitis Optic Neuritis Ringing in Ears Deafness Chronic Ear Infection Sinusitis Difficulty Swallowing Cancer CARDIOVASCULAR Hypertension Hypotension Myocardial Infarction Heart Attack Angina/Chest Pain Congestive Heart Failure Rapid Heart Rate (Tachycardia) Slow Heart Rate (Bradycardia) Irregular Heart Rate (Arrhythmia) Heart Murmur Mitral Valve Prolapse Rheumatic Heart Disease High Cholesterol/Lipids Vascular Disease (Legs-Arms) RESPIRATORY Asthma Chronic Bronchitis Tuberculosis Cancer Pneumonia MUSCULOSKELETAL Chronic Low Back Pain Chronic Neck Pain Muscle Disease Lupus Gout Rheumatoid Arthritis Osteoarthritis Fibromyalgia Connective Tissue Disease ENDOCRINE Diabetes Hyperthyroidism Hypothyroidism Cushing's Disease Addison's Disease Cancer DERMATOLOGY/HEMATOLOGY Anemia Leukemia Lymphoma Bleeding Disorder Psoriasis Skin Cancer HIV Positive AIDS GASTROINTESTINAL Ulcer Esophagitis Jaundice Hepatitis Gallstones Gallbladder Inflammation Pancreatitis Crohn's Disease Ulcerative Colitis Diverticulosis GERD Acid Reflux Cancer Page 6 of 11
8 PAST MEDICAL HISTORY (Continued) Past Present Past Present GENITOURINARY Pyelonephritis Kidney Stones Urinary Tract Stones Recurrent Infection Urinary Retention Cancer MEN ONLY Prostate Problems Impotence Cancer WOMEN ONLY Menstrual Problems Hormone Therapy Birth Control Pills Menopause Breast Cancer Other Cancer Endometriosis PSYCHOLOGICAL Depression Panic Attacks Anxiety Intellectual Loss Memory Loss Bipolar Disorder NEUROLOGICAL Alzheimer's Disease Stroke Brain Hemorrhage Transient Ischemic Attack Paralysis Brain Tumor Spinal Cord Tumor Seizure Epilepsy Syncope/Fainting Parkinson's Disease Tremor Spinal Cord Disorder Myopathy Other Muscular Disorder Nerve Injury Neuropathy Multiple Sclerosis Meningitis Encephalitis Arnold-Chiari Malformation Head Trauma/Injury Headaches Migraines Page 7 of 11
9 PLEASE LIST ALL PREVIOUS HOSPITALIZATIONS: Hospital Date Doctor Diagnosis PLEASE LIST ANY OTHER MEDICAL ILLNESS NOT PREVIOUSLY LISTED: Illness Past Present PLEASE LIST ALL MEDICATIONS YOU ARE NOW TAKING AND DOSAGE: Page 8 of 11
10 PLEASE LIST ALL MEDICATIONS TO WHICH YOU ARE ALLERGIC: FAMILY HISTORY Hypertension Peripheral Vascular Disease Diabetes Psychiatric Illness Coronary Artery Disease Kidney Disease Cancer Suicide Heart Attack Stroke Tuberculosis Parkinson's Disease Heart Surgery Brain Tumor Asthma Muscle Disease Other Heart Disease Epilepsy Other Lung Disease Peripheral Nerve Disease High Cholesterol Migraine Ulcer Disease Multiple sclerosis SOCIAL HISTORY 1) Marital Status (3) Cigarette Smoker (3) Daily Caffeine Consumption Married Yes Never Divorced Past Moderate Single No Occasional Widowed Present Excessive (2) Alcohol Intake (4) Cigar or Pipe Smoker (4) Education Never Yes Elementary School Moderate Past College Occasional No High School Excessive Present Post Graduate School (5) Cigarette Smoker Yes No Page 9 of 11
11 REVIEW OF SYSTEMS Constitutional Fatigue Weight loss Weight gain Change in bowel habits Eyes Change in visual acuity Double vision Transient visual loss ENT Difficulty swallowing Hearing loss Change in smell Cardiovascular Chest pain Angina Irregular heart rate High blood pressure Leg pan; arm pain Vascular changes in extremity Respiratory Shortness of breath Chronic cough Cough up blood Wheezing Gastrointestinal Abdominal pain Diarrhea Constipation GI bleeding Jaundice Skin Skin Lesions Neurological Seizures Numbness in extremities Muscle weakness Paralysis Tremor Difficulty with gait Involuntary movements Vertigo Unsteadiness of gait Facial pain Difficulty with speech Psychiatric Intellectual loss Depression Anxiety Panic spells Endocrine Hormone problems Diabetes Thyroid disease Other endocrine disease Musculoskeletal Back pain Neck pain Joint swelling Motor weakness Extremity pain Genitourinary Incontinence Blood in urine Cannot urinate Female problems Male problems AS (Rev. 06/122/10) Page 10 of 11
12 Please list any other Neurologists seen for headaches: Name Year Please list any other Headache Specialists or Clinics where you have been treated for headaches: Name Year If there is additional information regarding your condition or medications, etc., which you wish to include, please use the remainder of this page: Page 11 of 11
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Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
LAKES INTERNAL MEDICINE
LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education
MEDICAL HISTORY. Previous Nephrologist. Medication taken Insulin Oral Both. Who manages your diabetes? Blindness Yes No Hearing Problems Yes No
MEDICAL HISTORY Please mark YES or NO and fill in appropriate blanks as needed Chronic Yes No If yes, year diagnosed Previous Nephrologist Transplant Yes No If yes, date Donor type Living Deceased Related
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
ACTIVE EDGE CHIROPRACTIC
ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Email: Occupation: Birth
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy This form must be scanned into the medical record. Do not remove from clinic. UWMC Women s Health Care Center & SCCA Women s Cancer Center
John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle
NEW PATIENT INFORMATION
OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
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:
Cooper Neurological Institute Phone: Fax:
Cooper Neurological Institute Phone: 856-968-7965 Fax: 856-968-8697 PATIENT INFORMATION AND HEALTH HISTORY Name: Date: Birth date: Age: Home Phone: Cell Phone: If patient is a minor or disabled, please
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 Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
Last Name First Name Middle Name MRN
Dr. Byers Dr. Su Dr. Sponzilli Lisa Elvin, NP Spine Center New Patient Form Last Name First Name Middle Name MRN This form is used to gather information so that my doctor can maximize the time used to
SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE
Patient Name MRN DATE: SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE Date of birth Age REASON FOR VISIT Abnormal Mammogram R L please specify Lump/Thickening R L upper lower inner outer Pain R L upper
Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)
Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
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
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
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
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:
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
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
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
RAJIV SOOD MD, FACS AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY MEDICAL HISTORY Today s Date: Name Date of Birth
RAJIV SOOD MD, FACS AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY MEDICAL HISTORY 317-880-6825 Today s Date: Date of Birth Phone # Alternate # Age Height Current weight Significant other Name: Reason for
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