Phone (573) * Fax (573) PATIENT HISTORY FORM. Name Date of Birth M/F. Reason for Appointment Height
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1 Phone (573) * Fax (573) PATIENT HISTORY FORM Name Date of Birth M/F Date and Time of Appointment Referring Physician Preferred Pharmacy Reason for Appointment Height PHYSICIANS (Please list all doctors and/or practitioners providing healthcare) Type of Doctor Doctor s Name Primary Care, Oncology, etc. Reason for seeing this doctor ALLERGIES Do you have ANY allergies to drugs or foods? YES or NO Allergy list medication, foods, latex, etc. Reaction rash, shortness of breath, hives, itching, etc. CURRENT MEDICATIONS Please list ALL prescription medications, over-the-counter medications and vitamins!! Medication Dosage (mg, mcg, etc.) How often do you take? Prescribing Physician Page 1 of 5
2 REVIEW OF SYSTEMS Circle if you are experiencing symptoms or check No symptoms General Respiratory Genitourinary Recent fever/chills Cough (dry or productive) Blood in urine Recent weight loss/gain Coughing up blood Pain with urination How much? lbs. History of asthma, COPD History of kidney stones or emphysema Prostate problems (males only) Integumentary (Skin) Snoring Short of breath at rest or exertion Rash (of any kind) Neurological Changes in nails or hair Cardiovascular Changes in moles No symptoms Headaches Chest pain, pressure, tightness or Numbness/tingling on one side Eyes discomfort Weakness on one side Have you passed out? Dizziness Blurred vision Palpitations/irregular heart beats History of TIA, stroke or seizures Double vision Shortness of breath lying flat Wear glasses Swelling of feet or ankles Endocrine Glaucoma History of blood clots or phlebitis Cataracts Increased fatigue Legally blind Gastrointestinal Diabetes (Do you take insulin?) Excessive thirst Ears, Nose & Throat Blood in stools Increased urination Black, tarry stools Hyperlipidemia Hearing loss (hearing aid?) Heartburn or peptic ulcers Hyperthyroidism/hypothyroidism Nose bleeds Acid reflux (GERD) Seasonal sinusitis Hematological Musculoskeletal Psychiatric Bleed easily Muscle weakness/pain/cramps Bruise easily Anxiety Back pain (chronic) B 12 deficiency Stress Arthritis, generalized Bleeding disorders (anemia, etc.) Depression Rheumatoid arthritis Seasonal allergies History of alcoholism Swelling (if so, where?) History of drug abuse If you are experiencing chest pain of any kind, please describe the pain/discomfort. Are there any specific activities that seem to cause the pain? Does the pain radiate into you neck, jaw, arm, or back? Does it come on with exercise only, or does it also occur at rest? Did you experience any nausea or vomiting? Also, please describe any other symptoms you are having not mentioned above. Page 2 of 5
3 PAST MEDICAL HISTORY Circle past history below Past Illnesses Past Cardiac Illnesses Anemia Angina/chest pain Arthritis Atrial fibrillation (A-fib) Asthma Congestive heart failure (CHF) Bronchitis Coronary artery disease (CAD) Cancer, if yes, what kind? Heart attack (MI) Carotid artery disease High blood pressure Depression High cholesterol Diabetes, if yes, are you on insulin? Irregular heartbeat (arrhythmias) Erectile dysfunction Peripheral Vascular Disease/Claudication Gastrointestinal bleeding Pulmonary Hypertension Kidney stones/kidney failure/hemodialysis Endocarditis Liver/gallbladder Peptic ulcer GERD Prostate Rectal bleeding Seizures Sleep apnea, if yes, do you wear CPAP/BIPAP? Surgeries/Procedures/Dates Trauma History Stroke/CVA/TIA Appendectomy Motor-vehicle accident Thyroid disease Back Breast Carotid Cataract Gallbladder Infectious Diseases Hernia hiatal/inguinal Rheumatic fever Hip Scarlet fever Hysterectomy Chickenpox, measles, mumps, or rubella Intestinal Tuberculosis (TB) Knee Hepatitis A, B, C, D or E Amputation HIV/AIDS Lung Bariatric (gastric bypass, LAP-BAND) Cardiac surgery/procedures (Please provide dates and location and name of doctor if available) Cardiac catheterization Cardioversion Coronary angioplasty/stent Coronary artery bypass Electrophysiology study Implantable cardiac defibrillator (ICD) Pacemaker Radiofrequency ablation Heart valve surgery PAD Questionnaire How far can you walk before experiencing leg pain/fatigue or aching? Is it relieved with rest? Does leg pain prevent you from walking normally, with family/friends, or shopping? Is it relieved with rest? Any changes in toenails? Poor or non-healing wounds of legs or feet? Do you ever experience coolness or pallor of feet? Do you have a history of any other vascular abnormalities (carotid artery stenosis, abdominal aortic aneurysm, renal artery stenosis, or coronary artery disease)? Page 3 of 5
4 SOCIAL HISTORY & LIFESTYLE Alcohol use Do you consume alcohol? YES NO Average number per day/week/month? Beer Wine Liquor/mixed drinks Smoking/Tobacco use Do you smoke cigarettes/smokeless cigarettes or use tobacco? YES NO Are you currently smoking? YES NO Have you smoked in the past? YES NO How many years? Packs per day? Diet Are you on any special diet (diabetic diet, etc.)? YES NO If yes, what type? Do you drink caffeinated beverages? YES NO If yes, how many per day? (coffee, tea, soda, etc.) Exercise Do you exercise on a regular basis? YES NO If so, what type of exercise? (minimum of 30 minutes per day, at least 3 times per week) Substance abuse Do you have any history of drug use? If yes, please specify YES NO Lifestyle Single Married Widowed Divorced Separated Partnered Occupation Please list Full-time Part-time Retired Disabled Student Unemployed Residence Lives alone Lives with spouse Lives with partner Lives with parents Lives with children Nursing home resident Assisted living resident PERSONAL CARDIAC RISK FACTORS History of tobacco use Family history of heart disease (immediate family, mother, father, brother, sister) History of high cholesterol History of high blood pressure History of diabetes Prior history of heart disease History of obesity Sedentary/inactive lifestyle Age (Male over age 45 Female over age 55) Menopausal female Page 4 of 5
5 FAMILY MEDICAL HISTORY Father Mother Sibling(s) Please specify brothers or sisters Please feel free to write in the margins of any page or attach your own additional paper if you need more room. Page 5 of 5
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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
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
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
Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone
Date Patient Last Name First Name Middle Name Gender (circle): Male Female Other: Marital Status (circle): Single Married Divorced Widowed Separated Home Address City State Zip Date of Birth Age Social
New Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist