Name MR# Date Name of your primary care physician: Name of your OB/GYN physician:
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1 Women s Specialty Care, Urogynecology Division Husam Abed, MD, and Paul Moore, MD Locations Mirror Lake 2925 Layfair Drive, Flowood, MS Jackson Medical Mall 350 Woodrow Wilson Drive, Jackson, MS Phone: Fax: Name MR# Date Name of your primary care physician: Name of your OB/GYN physician: Reason for your visit: Please check all problems that affect you. How bad is your problem on a scale of 1-10? How long have you had this problem? Urinary Problems Stool Problems Vaginal Problems I usually have constipation I usually have diarrhea I have stool accidents or leak stool with: Leakage of gas Leakage of liquid stool Leakage of solid stool Constant urge to go to the bathroom I go to the bathroom every min hrs I wake up times to go to the bathroom at night I leak with cough, laugh, sneeze I have burning with urination I have difficulty with urination or feel the bladder does not completely empty after going to the bathroom I lose urine while sleeping I have pelvic pressure I have pelvic pain I can feel a bulge through the vagina I can feel something is falling out through the vagina Rate (1=not bad, 10=very bad) Rate (1=not bad, 10=very bad) Rate (1=not bad, 10=very bad) # of years # of months # of years # of months # of years # of months Pad use, changing clothes: Type of pads Number of pads /day Number of clothing changes/day Number of times leak/day Number of pads /day Number of clothing changes/day Number of times leak/day How often do you feel this: daily weekly monthly Do you have: Do you: A strong urge to urinate when you hear the sound of running water Leakage with activity Leakage with intercourse Drink coffee or tea How many ounces daily? Drink large amounts of fluid daily? How many ounces daily? Leakage with certain foods Leakage with constipation Leakage with diarrhea Have a history of a tear or episiotomy at childbirth Have anal intercourse To use hands/fingers to urinate or have bowel movement To change your position in the bathroom to urinate Have vaginal intercourse Is intercourse painful? Please mark any treatments you had in the past. Medication Pessary Surgery Medication Pessary Surgery Medication Pessary Surgery
2 Current Medications: Please list any prescription and non-prescription drugs. OB/GYN History: Please circle all that apply. Abnormal pap No cycles Breast cancer Cervical cancer Chlamydia Pre-cervical cancer Pain with cycles Pain with intercourse Eclampsia Endometrial polyp Endometriosis Fibroids Genitals warts Gestational diabetes Gonorrhea Herpes HIV/AIDS Hormone problems Infertility Heavy cycles Osteoporosis Ovarian Cancer Polycystic ovarian syndrome Pelvic inflammatory disease Postpartum depression Preeclampsia RH negative Syphilis Urinary incontinence Uterine cancer Vaginal cancer Vulvar cancer Other: Medical History: Please circle all that apply. Anemia Anesthetic complications Anxiety Asthma Blood dyscrasia Blood transfusion Breast problems Clotting disorder Coronary artery disease Depression Diabetes mellitus Heart murmur Hepatitis Hypertension Kidney disease Liver disease Lupus Mental disorder Osteoporosis Seizures Sickle Cell anemia Drug abuse Thyroid disease Trauma/Violence Urinary incontinence Varicosities/Phlebitis Other: Surgical History: Please circle all that apply Abdominal surgery Appendectomy Bladder suspension Breast enhancement Breast Surgery C-Section Colon surgery Vaginal surgery Colposcopy Cosmetic surgery D&C (dilate & curettage) Endometrial ablation Cryosurgery Hysterectomy Hysteroscopy Laser conization LEEP Right ovary removed Left ovary removed Pelvic laparoscopic surgery BTL (bilateral tubal ligation) Right tube removed Left tube removed Other:
3 Family History: Please circle all that apply and note if it is M-maternal (mother s side) or P-paternal (father s side) with the disease. Breast cancer Colon cancer Ovarian cancer Uterine cancer Asthma Diabetes Depression Endometriosis Heart attack Heart disease High Cholesterol Hypertension Lupus Mental illness Osteoporosis Polycystic ovarian disease Thyroid disease Prostate cancer Other:_ Social History: Please provide the following information about your health history. Alcohol use: Yes / No glasses of wine per week cans of beer per week shots of liquor per week Sexually active: Yes / No / Not currently Partners: Male / Female / Both male and female Birth Control/Protection: Abstinence / Condoms / Diaphragm / Implant (Nexplanon) / Injection / IUD / Birth control pill / Contraceptive patch / Vaginal ring / Spermicide sponge Other: Drug use: Yes / No If yes please list: Tobacco use: Never a smoker / Current every day smoker / Current some day smoker / Former smoker Smokeless tobacco: Never used / Current user / Former user Ready to quit tobacco products? Yes / No Occupation: Employer: Marital status: Single / Married / Separated / Divorced / Widowed Years of education: Number of children:
4 OB History: # of pregnancies: # of live births: # of miscarriages: # of abortions: # of living children: Delivery date/s: Vaginal or C- section delivery? Birthweight/s: Weeks at delivery? Male or Female? Complications? Menstrual History: Date of last period: Age cycles started: Period cycles (days) Period durations (days) Period pattern: Regular / Irregular Menstrual flow: Light / Moderate / Heavy Menstrual control: Panty liner / Thin pad / Maxi pad / Hospital pad / Tampon / Other: Pain during cycles: None / Mild / Moderate / Severe Preventative Health Maintenance History: Date of last OB/GYN visit: Provider s name: Date of last PCP visit: Provider s name: Date of last pap smear: Location: Date of last mammogram: Location: Date of last colonoscopy: Location: Date of last bone density: Location: Practice self-breast exams: Yes / No Regular exercise: Yes / No Healthy Diet: Yes / No Violence at home: Yes / No Depression: Yes / No
5 General- Weight loss or gain Fatigue Fever or chills Weakness Trouble sleeping Skin- Rashes Lumps Itching Dryness Color changes Hair and nail changes Breasts- Lumps Pain Discharge Self-exams Breast-feeding Respiratory- Cough Sputum Coughing up blood Shortness of breath Wheezing Painful breathing Review of Systems (Circle all that apply) Cardiovascular- Chest pain or discomfort Tightness Palpitations Gastrointestinal- Swallowing difficulties Heartburn Change in appetite Nausea Change in bowel habits Rectal bleeding Constipation Diarrhea Yellow eyes or skin Urinary- Frequency Urgency Burning or pain Blood in urine Incontinence Vascular- Calf pain with walking Leg cramping Musculoskeletal- Muscle or joint pain Stiffness Back pain Redness of joints Swelling of joints Trauma Neurologic- Dizziness Fainting Seizures Weakness Numbness Tingling Tremor Hematologic- Easy bruising Easy bleeding Endocrine- Head or cold intolerance Sweating Frequent urination Thirst Change in appetite Psychiatric- Nervousness Stress Depression Memory loss
6 INFORMATION FOR YOUR PHYSICIAN Part 1 Instructions: Answer these questions by putting an X in the appropriate box. If you are unsure about how to answer a question, give the best answer you can. While answering these questions, please consider your symptoms over the past several months. 1. Do you usually experience pressure in the lower abdomen? 2. Do you usually experience heaviness or dullness in the pelvic area? 3. Do you usually have a bulge or something falling out that you can see or feel in the vaginal area? 4. Do you usually have to push on the vagina or around the rectum to have or complete a bowel movement? 5. Do you usually experience a feeling of incomplete bladder emptying? 6. Do you ever have to push up on a bulge in the vaginal area with your fingers to start or complete urination? 7. Do you feel you need to strain too hard to have a bowel movement? 8. Do you feel you have not completely emptied your bowels at the end of a bowel movement? 9. Do you usually lose stool beyond your control if your stool is well formed?
7 10. Do you usually lose stool beyond your control if your stool is loose or liquid? 11. Do you usually lose gas from the rectum beyond your control? 12. Do you usually have pain when you pass your stool? 13. Do you experience a strong sense of urgency and have to rush to the bathroom to have a bowel movement? 14. Does a part of your bowel ever pass through the rectum and bulge outside during or after a bowel movement? 15. Do you usually experience frequent urination? 16. Do you usually experience urine leakage associated with a feeling of urgency, that is a strong sense of needing to go to the bathroom? 17. Do you usually experience urine leakage related to coughing, sneezing, or laughing? 18. Do you usually experience small amounts of urine leakage (that is, drops)? 19. Do you usually experience difficulty emptying your bladder? 20. Do you usually experience pain or discomfort in the lower abdomen or genital region?
8 Part 2 Are you having sexual relations? Yes No If you answered yes, we would appreciate it if you would fill out the questions below. If no, please go to Part 3. Instructions: Following are a list of questions about you and your partner s sex life. All information is strictly confidential. Your confidential answers will be used only to help doctors understand what is important to patients about their sex lives. Please check the box that best answers the question for you. While answering the question, please consider your sexuality over the last several months. 1. How frequently do you feel sexual desire? This feeling may include wanting to have sex, planning to have sex, feeling frustrated due to lack of sex, etc. Daily Weekly Monthly Less than once a month Never 2. Do you climax (have an orgasm) when having sexual intercourse with your partner? 3. Do you feel sexually excited (turned on) when having sexual activity with your partner? 4. Are you satisfied with the variety of sexual activities in your current sex life? 5. Do you feel pain during sexual intercourse? 6. Are you incontinent of urine (leak urine) with sexual activity? 7. Does fear of incontinence (either stool or urine) restrict your sexual activity? 8. Do you avoid sexual intercourse because of bulging in the vagina (either the bladder, rectum, or vagina falling out)? 9. When you have sex with your partner, do you have negative emotional reactions such as fear, disgust, shame or guilt? [ ] Always [ ] Usually [ ] Sometimes [ ] Seldom [ ] Never 10. Does your partner have a problem with erections that affect your sexual activity? 11. Does your partner have a problem with premature ejaculation that affects your sexual activity?
9 Part 3 Instructions: Some women find that bladder, bowel, or vaginal symptoms affect their activities, relationships, and feelings. For each question, place an X in the response that best describes how much your activities, relationships, or feelings have been affected by your bladder, bowel, or vaginal symptoms over the last several months. Please mark an answer in all 3 columns for each question. How do symptoms or conditions related to the following usually affect your Bladder or urine Bowel or rectum Vagina or pelvis 1. Ability to do household chores (cooking, housecleaning, laundry)? 2. Ability to do physical activities such as walking, swimming, or other exercise? 3. Entertainment activities such as going to a movie or concert? at all 4. Ability to travel by car or bus for a distance greater than 30 minutes away from home? Somewhat 5. Participating in social activities outside your home? at all Not at all 6. Emotional health (nervousness, depression, etc.)? 7. Feeling frustrated?
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Name Social Security Number Address: Street: _ New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification Date of Birth Gender: Male Female City: State Zip Code E-mail: Home Phone:
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
Patient Interview Form
Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information
New Patient History. Patient Name: Date of Birth: Reason for Today s Visit: Today s Date: Who is your Primary Care Physician (PCP)?
ew Patient History Patient ame: Date of Birth: Reason for Today s Visit: Today s Date: Who is your Primary Care Physician (PCP)? Review of Systems Please circle any concerning symptoms you are currently
A. Please include any medications (herbal, prescription, or Over-the-counter) and any supplements that you are currently taking.
New Patient Questionnaire Please complete this and bring it with you to your visit. If you have it completed five days or more prior to your visit, please mail or fax it to our office. Most recent treating
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
Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
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
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
Marcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)
Marcelo Garzon HOM.DSHomMed.Bsc. www.sagehomeopathy.ca (Please be certain that all in take forms are completed and returned on time) NAME: Personal Health History DATE: OHIP # D.O.B : AGE: PHONE: MAY WE
Pure Health Natural Medicine
Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell
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
SANTA MONICA BREAST CENTER INTAKE FORM
SANTA MONICA BREAST CENTER Who referred you to see us today? Who is your primary care physician? Are there any other MDs who you would like to receive today s visit information? No Yes MD contact info
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
Patient Interview Form
Page 1 of 6 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Race Select
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:
Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression
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
Heart Murmur Chest Pain Palpitations Swelling of feet Shortness of breath
Neck: Goiter Lumps Swollen Glands Pain Respiratory: Cough Wheezing Shortness of breath Coughing up blood Cardiac: Heart Murmur Chest Pain Palpitations Swelling of feet Shortness of breath Gastrointestinal:
Welcome to Aguirre Specialty Care (ASC). We are pleased that you have chosen us to evaluate your condition.
Dear Valued Patient, Welcome to Aguirre Specialty Care (ASC). We are pleased that you have chosen us to evaluate your condition. To facilitate your visit and ensure that ASC will be able to help you, we