MARK L. THORNTON, MD, FACP / EXECUDOC, INC.
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- Meghan Stewart
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1 MARK L. THORNTON, MD, FACP / EXECUDOC, INC. PATIENT INFORMATION In order to provide the best medical care possible, I must know not only what your present symptoms are, but also what diseases you have been exposed to and what problems you may be at risk for developing. For this reason you are requested to carefully fill out this screening health questionnaire. This along with the history and examination I will obtain when you visit with me will provide a complete medical evaluation of your current and potential medical problems. Date: Patient s Name (Last, First): Sex: o F o M DOB: Age: Marital Status: o Married o Single o Widowed o Divorced SSN: Mailing Address: (Street, City, State, Zip): Home Address: (Steet, City, State, Zip): Home Phone ( ) Work Phone ( ) Cell Phone ( ) Home Fax ( ) Work Fax ( ) Address: What is your primary means of contact? o Home Phone o Work Phone o Cell Phone o o Fax (Home or Work) Insurance Company: Policy No: Group No: Primary Insured: o Self o Spouse o Parent Primary Insured Name SSN DOB PLEASE COMPLETE THE FOLLOWING QUESTIONS: Please state why you are coming to see the doctor: What are your expectations of this visit? INJURIES ~ Please list serious injuries and broken bones with approximate dates: OPERATIONS ~ Please list the operations you have had, do not omit minor operations such as tonsils, vasectomy, D&C, etc.: Operation: Date: Hospital: Surgeon:
2 Hospitalizations ~ Please list your hospitalizations other than those described above: Illness: Date: Hospital: Physician: MEDICATIONS ~ Please list all current medications including vitamins and supplements: Medication: Strength: Dosage: Medication: Strength: Dosage: PLEASE CHECK ANY OF THE FOLLOWING THAT YOU HAVE BEEN TROUBLED WITH: GENERAL: o Weight loss (how much ) o Weight gain (how much ) o Over what period of time? o Poor appetite o Weakness o Night sweats SKIN: Dermatologist: Phone no: Date of last exam: o Burning o Rash o Hives o Acne o Psoriasis o Melanoma o Change in mole HEAD: o Headache (more than one per week) o Dizziness/lightheadedness o History of migraines EYES: o Double vision o Blurred vision o Redness o Tearing Ophthalmologist: Phone no: Date of last exam: EARS: o Earache o Drainage or discharge from ear o Vertigo o Tingling or other noises o Difficulty hearing (how long? ) NOSE: Do you frequently have a stuffy nose when you do not have a cold? o Yes o No o Frequent nose bleeds o Post nasal drip o Trouble smelling o Allergies (If yes, to what?) MOUTH: o Dentures o Dry mouth o Sore or burning tongue o Problems with teeth o Changes in taste o Hoarseness o Frequent sore throats o Gingivitis NECK: o Frequent stiffness o Goiter o Pain o Frequent swollen glands BREASTS: o Tenderness o Nipple discharge o Lumps or masses o Breast biopsy o Family history of breast cancer. Who?
3 RESPIRATORY: o Cough o Coughing up blood or blood streaked phlegm o Pneumonia o Bronchitis o Wheezing/asthma o Sputum (phlegm) production in the morning o Emphysema o Coughing after eating CARDIOVASCULAR: o Palpitations o Thumping in the chest o Irregular heart beat o Fainting spells o Swelling of ankles o Cramps in your legs on walking o Cramps in leg at night o Nocturnal cough o Shortness of breath o Chest pain or discomfort/angina o High blood pressure o Congestive heart failure o Heart murmur/abnormal heart valve o Can you climb two flights of stairs without stopping? o Yes o No GASTROINTESTINAL: o Pain o Heartburn o Intolerance to any foods o Vomiting o Diarrhea o Constipation o Recent change in bowel habits o Jaundice o Clay colored stools o Black or tarry stools o Blood in the stool or on toilet paper o Rectal itching o Gall bladder trouble o Ulcers o Vomiting of blood or coffee ground-like material o Liver disease o Cirrhosis o Hiatal hernia o Pancreatitis o Diverticulitis o Hemorrhoids o Esophagitis/reflux o Colon polyps o Family history of colon cancer: o Yes o No Colonoscopy: Date: Gastroentorologist: GENITOURINARY: o Kidney Stones o Blood in urine o Coca cola colored urine o Urgency o Burning o Straining on urination How many times do you get up at night to urinate? How long have you been doing this? MEN: o Discharge from penis o Prostatitis o Pain or swelling o Erectile dysfunction o Last PSA or rectal exam: WOMEN: o Discharge from vagina o Itching o Cramps o Bleeding between periods Date of last pelvic exam? Date of last PAPS smear? Date of last menstrual period? Do you use birth control pills? o Yes o No Onset age of mentrual period? Days between periods? Duration of flow? Date of last bone density exam? PREGNANCIES? How many pregnancies? Live births? Weight of largest baby? During pregnancy, did you have any of the following? o Diabetes o Seizures o High blood pressure o Swelling of ankes o Albumin or protein in urine MUSCULOSKELETAL: o Arthritis o Joint stiffness in the morning o Bone pain o Muscle pain o Swollen joints o Low back pain o Varicose veins o Phlebitis o Cold or blue fingers o Rheumatoid arthritis
4 NEUROLOGICAL: o Seizures o Epilepsy o Stroke o Paralysis o Muscle weakness o Tremors o Muscle wasting o Numbness o Neuritis o Fainting GLANDS: o Goiter o Thyroid disease o Diabetes o Change in texture of hair BLOOD: o Anemia o Easy Bruisability o Bleeding disorders PSYCHIATRIC: o Insomnia o Hopeless feeling o Feeling Blue o Crying o Shyness o Difficulty relaxing o Excess worrying o Sexual problems o Fatigue o Thoughts of suicide o Loss of interest in pleasurable activities Have you ever been hospitalized for emotional reasons? o Yes o No Have you ever been on medication for emotional reasons? o Yes o No Reason/diagnosis: Have you ever been to see a psychiatrist or psychologist? o Yes o No Name: ALLERGIES ~ Please provide a complete list of all allergies: Allergen (including medications) Type of reaction: Date of last reaction: HABITS ~ Please indicate your average daily consumption of the following and how long you have used them: Alcohol Coffee Beer Tea Cigarettes/ Wine smokeless tobacco Marijuana Pipes & cigars EMPLOYMENT What type of work do you do? What type of work does your spouse do? IMMUNIZATIONS ~ Please indicate the last year you received each of the following immunizations: Tetanus Infuenza (flu) Hepatitis B TB Skin Test o Positive o Negative Pneumonia Measles/Mumps/Rubella (MMR)
5 FAMILY HISTORY ~ Please include hypertension, heart disease, cancer, diabetes, thrombosis, etc. Family Member Age if Alive Age at Death Medical Problems or Cause of Death Spouse Mother Father Brothers Sisters Children Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather COMMENTS:
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MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment
Holistic Health Care New Patient Intake Form
Holistic Health Care New Patient Intake Form Name * Address * Telephone number: * Email Address * May we use your email address occasionally for health related information? * Are you a current or past
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
Gender: M F Race: Caucasian African American Hispanic Other
Weight Loss Surgery Patient Information First Name: Middle Initial: Last: Date of Birth: Age: Social Security #: Gender: M F Race: Caucasian African American Hispanic Other Address: City: State: Zip: Home
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
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 These questions are general screening questions designed to identify areas where additional attention may be required. Please bring
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
HILL PARK MEDICAL CENTER PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Address: City: Contact: State: Zip: Home Phone: Email: Work: Cell: Date of Birth: SSN#: Age: Gender: I am: q Married q In a Partnership q Separated q Divorced q Widowed q Single
New Patient Specialty Intake Form Department of Surgery
This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient