New Patient Questionnaire
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- Marsha Houston
- 6 years ago
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1 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 care team in better assessing your health status. PART I: GENERAL INFORMATION PLEASE PRINT CLEARLY Name MGH Unit # Address Date of birth Home Phone ( ) Work Phone ( ) Name of spouse or significant other : Seasonal address and phone (if applicable): Months typically away: Seasonal Home Phone ( ) Seasonal Work Phone ( ) Patient s occupation: Check if retired Employer: City/Town: Person to contact in case of emergency: Name: Address: Primary Care Physician/Internist: Relationship: Home Phone ( ) Work Phone ( ) Dr. Address Office Phone ( ) Office Fax ( ) Names of any other physicians / specialists actively involved in your care: By whom were you referred for today s visit? THERE ARE FOUR MORE PAGES TO GO Patient identification
2 Mass General/North Shore Cardiology New Patient Questionnaire Page 2 of 5 PART II: MEDICAL HISTORY Medical and Surgical history: Please list all of the medical/surgical history and illnesses you have presently or have had in the past: Have you had any of the following tests or procedures? Stress test: No Date: Hospital: Cardiac catheterization: No Date: Hospital: Coronary stent/angioplasty: No Date: Hospital: Cardiac surgery: No Date: Hospital: Peripheral Vascular (arterial or venous) procedure: No Date: Hospital: Medications: (May attach a medication list) Please list all prescription and over-the-counter medications you take on a regular basis (include vitamins, herbal supplements, etc.): Medication name Dose (e.g. 50 mg) Frequency (e.g. 3x/day) Reason for taking this THERE ARE THREE MORE PAGES TO GO
3 Mass General/North Shore Cardiology New Patient Questionnaire Page 3 of 5 Preferred pharmacy: Phone ( ) City/town: Do you have insurance or a prescription plan to help pay for medications? No Does your prescription plan give you a 30 day or a 90 day medication supply? Allergies: Are you allergic to any medications? No known drug allergies If yes, please list specific medications and reactions: Are you allergic to intravenous contrast dye or gadolinium? No, or unknown If yes, what is your reaction? Habits: Do you smoke cigarettes? No, I have never smoked I currently smoke: How many packs per day and for how many years? Former smoker: When did you quit? ; After packs per day for years Have you ever attempted to quit and started smoking again? If so, # of times Do you smoke cigars or pipes? In the past Never smoked Do you drink any alcoholic beverages? Beer Wine Other alcohol # of drinks per day, per week How many cups of coffee do you drink? cups per day, decaf cups per day. Do you exercise regularly? No If yes, what form of exercise? for how many minutes, how many days per week? Have you ever tried to lose weight? No Do you follow any special diet? No Low Sodium Low Cholesterol Other. If other please describe: Do you follow any fluid intake restriction? No If yes, what volume: THERE ARE TWO MORE PAGES TO GO
4 Mass General/North Shore Cardiology New Patient Questionnaire Page 4 of 5 PART III: FAMILY Marital status: Single Married Divorced Widow/widower How many children do you have? What are their ages? If you are adopted, check here and skip to section IV. If not, please continue: How many brothers do you have? How many sisters do you have? Please indicate if any of your first-degree relatives (i.e., your parents, siblings, grandparents or children) have had any of the following cardiovascular conditions. Condition Coronary artery disease Angina Heart attack Angioplasty/stent Coronary artery bypass surgery *age of onset, if known Arrhythmias Irregular heart rhythms Cardiac arrest Congestive heart failure Weak heart Cardiomyopathy Aortic/Peripheral artery aneurysms Diabetes Hypertension High cholesterol Father- if deceased, cause/age of death: Mother- if deceased, cause/age of death: THERE IS ONE MORE PAGE TO GO
5 Mass General/North Shore Cardiology New Patient Questionnaire Page 5 of 5 PART IV: REVIEW OF SYSTEMS Do you have any of the following symptoms or problems? Check box if yes, leave blank if no or if you don t know. 1. General Excessive recent weight gain or loss Night sweats Fevers, chills 2. Head and Neck Severe headaches Recent hoarseness Bad teeth Dentures: If so, Partial 3. Respiratory Chronic cough Wheezing or asthma Coughing up blood Complete 4. Cardiovascular Elevated cholesterol High blood pressure A heart murmur Chest pain or pressure with exertion Shortness of breath with exertion Shortness of breath when you lie flat Waking up at night short of breath Ankle swelling Prior leg vein stripping Pain/cramping in calves while walking A history of palpitations Recurrent lightheadedness or dizziness Fainting or loss of consciousness 5. Gastrointestinal Frequent heartburn or indigestion Difficulty swallowing An ulcer Black or tarry stools Frequent nausea / vomiting 6. Hematologic Easy bruising Anemia 7. Urinary Frequent urination at night Frequent urinary tract infections Blood in urine 8. Neurologic A prior stroke Transient paralysis A transient neurologic deficit Seizures Muscular weakness/tingling Speech difficulty Double vision/loss of vision 9. Skin Any chronic rashes or eruptions Poor healing of foot lesions or wounds Moles that are changing in size 10. Endocrine Elevated blood sugars Thyroid problems 11. Female patients only Have you reached menopause? No If yes, at what age did you? If yes, are you taking hormone replacement therapy? No in the past Signature: Date: Thank you for taking the time to complete this new patient health questionnaire.
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Cardiovascular Genetics Clinic Vascular 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
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Inflammatory Bowel Disease Medical Exam Questionnaire
Patient Name: MR: Date: Name DOB / / Age Marital Status Race Gender M / F Height Present Weight Usual Weight Insurance Managed Care Self referral Yes No Yes No Yes No Primary Care Physician Referring Physician
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.
We are looking forward to meeting with you and assisting in your cardiac care. Thank you, Metropolitan Heart and Vascular Institute.
Thank you for scheduling an appointment at Metropolitan Heart and Vascular Institute. We are looking forward to meeting you. Enclosed are our patient registration forms. Please complete these forms to