NEW PATIENT VISIT QUESTIONNAIRE
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1 HeartHealth A Program of the Dalio Institute of Cardiovascular Imaging NEW PATIENT VISIT QUESTIONNAIRE Name: Date of Birth: / / Address: City: State: Zip: Home Phone #: Work Phone #: Cell #: Preferred Method of Communication: My Chart Cell Work Home Primary Care Physician: Office Address: Referring Physician (if different): Office Address: Pharmacy: Address: Medication prescription preference (circle one): 30 day supply 90 day supply Will you need translation services during your visit? Yes No If yes, please list the language required: Please note: We strongly recommend an English- speaking family member accompany you to your visit. Why are you here to see a cardiologist today? Please be as specific as possible (e.g., symptoms or tests.) PAST MEDICAL HISTORY: Do you personally have a history of: Known coronary artery disease? - "silent" heart attack (found incidentally) YES NO DETAILS (e.g., dates, hospitals, treating physicians) - heart attack(s) requiring hospitalization - coronary artery stenting - coronary artery ballooning only - coronary artery bypass surgery 1305 York Avenue, 8 th Floor, New York, NY Telephone: HART (4278) Fax:
2 YES NO DETAILS (e.g., dates, hospitals, treating physicians) Heart rhythm disorders? - pacemaker? - defibrillator (ICD)? - atrial fibrillation? - atrial flutter? - ventricular arrhythmias? - cardioversion? - ablation procedure? Heart failure? A heart murmur? Mitral valve prolapse? Rheumatic heart disease? High blood pressure (even if treated)? High cholesterol (even if treated)? Diabetes (even if treated)? Stroke? Aortic aneurysm (an enlarged aorta)? Thyroid disorder (hyper or hypo)? Asthma/Emphysema/COPD? Stomach/peptic ulcers? Gastrointestinal bleeding? Heartburn/Reflux (GERD)? Lung cancer? Colon cancer? Breast cancer? Prostate cancer? History of a blood clot (DVT/PE)? Bleeding disorder? PAST SURGICAL HISTORY (Cardiac): Heart valve repair? Heart valve replacement? Carotid artery surgery (endarterectomy)? Aortic aneurym repair/stenting? Peripheral artery bypass surgery? Congenital heart disease repair of: - Tetralogy of Fallot - atrial septal defect - ventricular septal defect 2
3 Have you ever had non- cardiac surgery before? Yes No If yes, please indicate dates and types of surgery: Do you currently smoke? Yes No Did you ever smoke? Yes No Did you ever use chewing tobacco or snuff? Yes No (If yes to any question, please indicate type of tobacco, amount per day, number of years, and quit date.) Do you currently drink? Yes No (If yes, please indicate type(s) of alcohol and approximate number of drinks per week for each type.) Are you: Married Single Divorced Widowed Other Do you currently work? Yes No Occupation: Please indicate your family members medical history as below: Father Mohter Brothers Alive? Heart High Emphysema First Name (Y/N) Age Disease? Cholesterol? Diabetes? Stroke? Cancer? or asthma? Sister(s) Son(s) Daughter(s) Other(s) For any family member you have indicated yes for heart disease above, please list the specific details below (e.g., heart attack, stents, bypass surgery, valve disease, atrial fibrillation, etc.) as well as the age of onset of the disease. If any family member died suddenly please indicate the age at death and if the cause was heart- related (e.g., heart attack, sudden death, stroke, etc.) Family member Age at onset/death Type of heart disease/cause of death 3
4 Do you have a living will? Yes No Do you have a health care proxy? Yes No If yes, please list contact information below: Name: Relation: Address: Home Phone #: Cell Phone #: Work Phone #: E- mail address: Fax # (if applicable): Please list ALL of your CURRENT medications below (if you need more room please use back of page): Medication (name) Amount Frequency taken (daily, every 6 hours, etc.) Approximate start Date of Medication Example: metoprolol 25 mg Once daily 2005 Do you take any non- prescription medications? Yes No If yes, please list below: Do you have any ALLERGIES to medications? Yes No If yes, please list medications and reactions: REVIEW OF SYSTEMS: Please indicate IF YOU ARE CURRENTLY EXPERIENCING any of the following signs and/or symptoms: YES NO YES NO CONSTITUTIONAL MUSCULOSKELETAL Recent change in weight? Pains in the joints (knees, hips, etc.)? Fevers? Chills? Night sweats? Decreased appetite? Muscle pains? Bone fractures? Pain in the bones (not joints)? GENITOURINARY Fatigue? Inability to sleep? Need to urinate frequently? Need to urinate suddenly and urgently? 4
5 YES NO YES NO EYES Recent change in vision? Double vision? Eye pain? EARS/NOSE/MOUTH/THROAT Hearing loss? Ringing in the ears? Pain in the ears? Nasal congestion? Runny nose? Post nasal drip? Nosebleeds? Sore throat? CARDIOVASCULAR Chest pains? Palpitations? Inability to sleep lying flat? Swelling in the legs or feet? Muscle pains in the legs with walking? Awakening feeling short of breath? Lightheadedness? Loss of consciousness? Decreasing exercise tolerance? RESPIRATORY Shortness of breath? Coughing up sputum/phlegm? Coughing up blood? Wheezing? GASTROINTESTINAL Nausea? Vomiting? Abdominal pains? Diarrhea? Constipation? Heartburn/reflux? Blood in the stool? Frequent urination at night (>1X)? Blood in the urine? Pain while urinating? Urinary incontinence? DERMATOLOGICAL New rashes? New ulcers? Recent hair loss? Recent change in skin? NEUROLOGICAL New weakness? New severe headaches? New memory loss? New seizures? Sensation of the world spinning? ENDOCRINOLOGIC New intolerance to heat? New intolerance to cold? Increased frequency of urination? Increased need to drink fluids? HEMATOLOGICAL Easy bleeding? Easy bruising? Swollen glands/lymph nodes? Current use of coumadin/pradaxa/xarelto? ALLERGIC/IMMUNOLOGIC Diffuse itching? Anaphylaxis? Swelling of the throat? PSYCHIATRIC Depressed mood? Inability to enjoy anything? Anxiety? Suicidal thoughts? Hallucinations? 5
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PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:
1 NAME: DATE OF BIRTH PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS: PAST MEDICAL HISTORY (YOUR MEDICAL HISTORY) :
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Patient Registration Form Name: Today s Date: FIRST MIDDLE LAST Home Address: City: State: Zip: Telephone: ( ) Birthdate: Age: Occupation: SSN: Employer: Years There: Employer s Address: City: State: Zip:
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
Health History Questionnaire:
Health History Questionnaire: Name Date of birth Address Local phone number Please describe what problem or concern brought you to our office today: Alternative phone number Primarily to establish care
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
GASTROCARE, P.C. Contact Preference: HOME: Cell #: Office #: REASON FOR VISIT: Allergies: Current Medications (Name/Dose/How taken):
GASTROCARE, P.C. DR. A.B. REDDY, M.D., F.A.C.G. DR. REKHA KHURANA, M.D. Referring Physician: First Name: Date of Birth: Last name: Age: Pharmacy (include location): Fax Number: Email Address: Gender: Male
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