INFINITY PRIMARY CARE
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- Ada Pope
- 5 years ago
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1 INFINITY PRIMARY CARE ADULT HISTORY FORM PLEASE PRINT (with Blue or Black Ink) Today s Date: Physician: (last) (first) Date of Birth: Mail Order Pharmacy: Phone: Fax: Local Pharmacy: Phone: Fax: Language Spoken at home: MEDICATIONS: ALLERGIES: Please list all medications (include over-the-counter?) Are you allergic to any drugs or medications? In preparation for your visit bring all medications, inhalers, NO YES If yes, what? vitamin or supplements in their original bottles. NAME STRENGTH FREQUENCY 1. Do you have any food allergies? NO YES If yes, what? Any other allergies? 4. NO YES If yes, what? 5. PAIN: Are you having pain today? NO YES 6. If yes, on a scale of =little or no pain and 10 = severe pain 7. What level are you at? REVIEW OF SYSTEMS: Please check any symptoms you have had RECENTLY Constitutional O Chills O Fatigue O Fever O Night sweats O Weight gain O Weight loss HEENT O Ear drainage O Ear pain O Eye discharge O Eye pain O Hearing loss O Nasal drainage O Sinus pressure O Sore throat O Visual changes Respiratory O Cough O Shortness of breath O Wheezing Cardiovascular O Chest pain O Leg pain when walking O Edema (swelling) O Palpitations Gastrointestinal O Abdominal pain O Blood in stool O Change in stool O Constipation O Diarrhea O Heartburn O Loss of appetite O Nausea O Vomiting Genitourinary O Painful urination O Blood in urine O Urinary frequency O Urinary incontinence Skin O Hair loss O Hives O Itching O Mole changes O Rash O Skin lesion (Female Only) O Breast discharge O Breast lump O Breast pain Reproduction (Female Only) O Abnormal Pap O Painful period O Painful intercourse O Hot flashes O Irregular menses O Vaginal discharge Last Period (Male Only) O Erectile dysfunction O Penile discharge Neurological O Dizziness O Extremity numbness O Extremity weakness O Gait disturbance O Headache O Memory loss O Seizures O Tremors Psychiatric O Anxiety O Depression O Insomnia Metabolic/Endocrine O Cold intolerance O Heat intolerance O Excessive thirst O Excessive hunger Musculoskeletal O Back pain O Joint pain O Joint swelling O Muscle weakness O Neck pain Hematologic/Lymphatic O Easy bleeding O Easy bruising O Enlarged lymph nodes Immunologic O Contact allergy O Environmental allergies O Food allergies O Seasonal allergies Page 1 of 4
2 In the last 2 weeks have you felt down, depressed or hopeless? (circle one) Not at all Several Days More than ½ the days Every Day Had little or no interest in doing things? (circle one) Not at all Several Days More than ½ the days Every Day CHRONIC CONDITIONS: Please mark any illness or disease you have had in the past or currently have: O Allergies O Cardiac arrhythmia O Head Injury O Seizure disorder O Anemia O Chronic Insomnia O Headache, migraine O Stomach Ulcers O Angina O Congestive Heart Failure O Heart disease O Stroke O Anxiety O COPD/Emphysema O Heart valve disorder O Thyroid disease O Arthritis O Coronary artery disease O Hepatitis/liver disease Specify O Depression O Hiatal Hernia O Asthma O Diabetes O High Blood Pressure Other-Specify O Atrial Fibrillation O High cholesterol O Irritable bowel syndrome O Eye Problems O Benign prostatic hypertrophy O Gall bladder disease O Macular Degeneration O Neck/Back Problems O Blood clots O GERD O Heart Attack O Bladder Problems O Cancer O Glaucoma O Osteoporosis O Psychiatric Illness Type O Gout O Kidney disease SURGICAL/HOSPITALIZATION HISTORY: (if marking an item below please include the year it occurred) O Angioplasty O Cardiac surgery O D and C O ORIF (Fracture surgery) O Appendectomy Type O Gastric Bypass O Prostate Biopsy O Arthroscopy O Carpal Tunnel Release O Hernia Repair O Thyroidectomy O Back Surgery O Cataract Extraction O Hip Replacement O Tonsillectomy O Bilateral Tubal Ligation O C-section delivery O Hysterectomy O Vasectomy O Bladder Suspension O Cervix Surgery/Procedure O Knee Replacement O Other O Breast Surgery O Gall Bladder Removal O LASIK Type O Colectomy O Liver Biopsy O Colostomy O Myomectomy What diagnostic, screening studies or immunizations have you had done previously? Please list most recent date. Complete Physical Last PAP Tetanus/Td/Tdap Vaccine Cardiac Stress Test Last Mammogram Pneumonia Vaccine Colonoscopy Bone Density (DEXA) Zostavax /Shingles Vaccine Cholesterol Have you had the chicken pox? Hepatitis A Vaccine Last Eye Exam Flu Vaccine Hepatitis B Vaccine Last Dental Exam Page 2 of 4
3 FAMILY HISTORY: Check below to report problems your family members have had. Please state age when they had the problem if you know it. Adopted (unknown family history) Mother Father Maternal Grandmother ADD/ADHD Alcoholism Alzheimer s disease Aneurysm Arthritis (Rheumatoid) Asthma Blood disorder /Clotting Cancer (list type) Heart Disease Depression Diabetes Elevated Lipids Genetic disease High Blood Pressure Inflammatory Bowel Syndrome Mental Illness Migraines Obesity Osteoporosis Seizure disorder Stroke Thyroid disorder Other Deceased? Age? Maternal Grandfather Paternal Grandmother Paternal Grandfather Sister Brother Child Page 3 of 4
4 SOCIAL HISTORY: Tobacco Usage: No Yes Quit Type? If yes or quit, how long? Packs per day? Vaping Usage: No Yes Quit Type? If yes or quit, age started? Contain Nicotine? Alcohol Usage: No Yes Quit Type? How Much? Caffeine Usage: No Yes Quit Type? How Much? Drug Usage: No Yes Quit Type? How Much? Occupation: Employed? Employer Military Experience: No Yes Current status: active reserves discharged retired military Marital Status: Married Single Life Partner Divorced Widowed If married, spouses name: Do you have any children? No Yes # of sons # of daughters # of stepsons # of stepdaughters # of adopted sons #of adopted daughters What is your activity level? Moderate Sedentary Vigorous Exercise Type: Frequency? 2-3 times/week 3-4 times/week daily never occasional Do you have a religious affiliation? No Yes Affiliation: Smoke Detectors in home? No Yes Do you wear seat belts? No Yes Carbon Monoxide Detectors in home? No Yes Firearms at home? No Yes Radon in home? No Yes Treated Untreated Are you sexually active? No Yes Not currently Please list all specialty Physicians that you have seen in the last year: Provider Provider Provider Provider The above information is correct to the best of my knowledge. Signature of Patient/Parent/Legal guardian/patient advocate/next of kin circle one Date Page 4 of 4
5 Physician: Visit Date: COMMUNITY LINKAGES SURVEY We are dedicated to you, our patient and your family. If you are comfortable, please take a moment to answer the following questions so that we can help connect you with local community resources. Our staff is ready to answer any additional questions that you may have. Please check Yes or No to the following questions: 1. In the past month, did poor physical or mental health keep you from doing your usual activities, like work, school or a hobby? 2. In the past year, was there a time when you needed to see a doctor but could not because it cost too much? 3. Do you ever eat less than you feel you should because there is not enough food? 4. Do you need a job or other steady source of income? 5. Are you worried that in the next few months, you may not have adequate housing that you own, rent or share? 6. In the past year, have you had a hard time paying your utility company bills? 7. Does getting child care make it hard for you to work, go to school or study? 8. Do you think completing more education or training, like earning a high school diploma, going to college, or learning a trade, would be helpful for you? 9. Do you need a dependable way to get to work or school and your appointments? 10. Do you need household supplies? For example, clothing, shoes, blankets, mattresses, diapers, toothpaste, and shampoo. 11. If you take medication, are you not taking it because it is too expensive? 12. Do you need help finding or paying for care for loved ones? For example, child care or day care for an older adult. 13. Do you feel unsafe in your home or living situation? If you answered Yes, would you like to receive assistance with any of these needs? Are any of your needs urgent, please write the Number of the Need (1-11)? My name: Date of Birth: Survey completed by (if other than the patient): My best telephone number: (version )
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MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
Date of Visit / / Date of Birth / / Age
New Patient Health Questionnaire Date of Visit / / Date of Birth / / Age Email Race: Non-Hispanic Hispanic Preferred Language: English Other Do you have advanced directives: living will, power of attorney
Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP
Patient Interview Form
Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: tes: Contact Preference Email Telephone call/leave message Patient declines to specify Email Please check one
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) :
Clermont Medical Center
Clermont Medical Center Stephen M. Asmann, M.D. 1135 Lake Avenue, P.O. Box 121009 Carol Takis, PA-C Memory Crowley, D.O Clermont, Florida 34712-1009 Sherri Sartin, PA-C Christopher Guzik, D.O. (352) 394-4035
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
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail