History Form for Exceptional Home-Based Care
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- Maud Sophie Dorsey
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1 Patient Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best care possible to our patients. Feel free to use additional pages to provide any information not included here that you think is important. Main reason for visit: Current/Past Medical Problems: Example Strokes, Heart trouble, High Blood Pressure, High Cholesterol, Thyroid Problems, Eye problems, etc History Form for Exceptional Home-Based Care Current or Past Medical Problem HomeCare Physicians 1800 N. Main Street Wheaton, IL Fax: Approximate date of diagnosis or onset Past Surgeries: Example Gall Bladder removed, Appendectomy, Hysterectomy with or without ovaries removed, Cataract surgery (note which eyes), Prostate surgery, Heart surgery, Angioplasty, Colonoscopy, hip surgery (note which side), etc. Past Surgery Approximate Date of Surgery Medical Allergies and reaction: Example rash, swelling, trouble breathing, etc. Medicine/Substance Allergic To Reaction
2 Medications: Please list both prescription and over the counter medication (such as pain relievers, constipation medicine, heart burn medicine, vitamins, etc.) and how many times a day medication is taken. For as needed medication please give an estimate of how often you take it such as daily, every other day, once a week, once or twice a month, etc. Add another sheet with additional medications if necessary. Medication and Strength (mg or mcg, etc.) How Often Taken or As Needed Local Pharmacy: ; Phone #: Mail Order Pharmacy: ; Phone #: Member ID #: ; Fax #: 6. Family History: Please list medical problems of close family members (example Dementia, Cancer and what type, Heart disease, Stroke, Diabetes, Hypertension, Depression, etc.). If deceased, please include age died. Underneath Mother list other close family members and their medical problems. Family Member Father Mother Brother Sister Age Died if Deceased Medical Problems or Cause of Death 2017 HCP; May reproduce for patient use. 2
3 7. Social History: Tobacco Use: Never ; Quit ; Current Smoker. Average packs per day: ; Years smoked: ; Quit Date: ; Type; Cigarette ; Cigar ; Pipe. Smokeless Tobacco: Current User ; Former User ; Never Used ; Unknown. Alcohol Use: None ; Number of drinks per week? Was drinking too much alcohol ever a problem for you? Yes ; No Recreational Drug Use: No ; Yes ; Type Sexual Activity: Not currently ; No ; Yes Who helps care for the patient: Tell us something the patient is proud of in their lifetime: Communication Preference: Native Language: English ; Other: ; Able to understand English: Yes ; No ; Able to read English: Yes ; No Past Occupation: ; Years of Education: Advance Directives: Durable Power of Attorney for Healthcare: Yes ; No ; Name and relationship: ; Living Will ; Do Not Resuscitate Form ; Would you like information on Advanced Directives: Yes ; No If you have any of the above documents please provide a copy. Religion/Faith: ; Is your faith important to you and does it affect your health care decisions: Finances: Are you have any trouble paying your bills: Yes ; No ; Are you going without anything you need like food, medications or other household or personal items: Yes ; No ; Durable Power of Attorney for Finance Yes ; No ; Name and relationship: ; 8. Ability to do Activities: Please mark or fill in the appropriate box below. Activity No Assist Total Assist Needs Partial Assistance: Please Describe Feeding Bathing Toileting Dressing Transferring Walking Housework Meal Preparation Manage Money Use Telephone 2017 HCP; May reproduce for patient use. 3
4 9. Review of Systems: Check or describe below any symptoms you are having: General: Fever ; Chills ; Weight loss ; Fatigue ; Sweating ; Weakness Height: Feet; inches; Any loss of height: inches Weight: pounds (Can estimate); Any weight loss: pounds over months. Skin: Rash ; Location: ; Itching ; Bed sore ; Location of bedsore and type of dressing: Head: Headaches ; Hearing loss ; Hearing aid ; Ringing in ears ; Ear pain ; Ear discharge ; Nose bleeds ; Nose congestion ; Sore throat ; Last Dental exam: Eyes: Blurred Vision ; Double Vision ; Light Sensitivity ; Eye pain ; Eye discharge ; Eye Redness ; Last eye exam: Heart: Chest pain ; Palpitations ; Trouble breathing lying flat ; Leg cramps ; Leg swelling Lungs: Cough ; Sputum production ; Shortness of breath ; Wheezing ; On Oxygen ; Oxygen flow rate: Gastrointestinal: Heart burn ; Nausea ; Vomiting ; Abdominal pain ; Diarrhea ; Constipation ; Blood in stool Genitourinary: Urinary burning ; Urgency ; Frequency ; Blood in urine ; Incontinence ; Musculoskeletal: Muscle aches ; Neck pain ; Mid-back pain ; Low-back pain ; Joint pain (Location: ); Pain intensity on scale of 1 (mild) to 10 (Severe): ; Fall in past year ; Endocrine: Easy bruising ; Environmental allergies ; Extreme thirst ; If diabetic Morning sugar range, Evening sugar range Neurological: Dizziness ; Tingling ; Tremor ; Sensory change ; Speech change ; Weakness on one side of body from stroke: Right / Left ; Trouble swallowing ; Seizures ; Loss of consciousness ; Psychiatric: Depression ; Suicidal thoughts ; Substance abuse ; Hallucinations ; Nervous/Anxious ; Insomnia ; Memory loss ; Over the past 2 weeks, how often have you been bothered by any of the following problems? Not at All Several Days More than Half the days Nearly Every Day Little interest or pleasure in doing things Feeling down, depressed or hopeless Caregiver questions: Caregiving can be both rewarding and challenging. Please let us know: Do you feel you are able to provide the care your relative needs? Yes ; No ; Comment: Do you feel you have time to take care of yourself? Yes ; No ; Comment: 2017 HCP; May reproduce for patient use. 4
5 1 Immunizations: Please contact your primary care doctor if you are not sure about what shots you have received before our visit. Immunization Yes Date No Unknown Refuses Influenza (Flu) Pneumovax (Pneumonia) Prevnar (Pneumonia) Tdap (Tetanus) Zostavax (Shingles) 1 Durable Medical Equipment: Please list any medical equipment you have in the home such as a bedside commode, wheel chair, walker, hospital bed, tube feeding pump, suction machine, etc. Please provide the name of the medical supplier and phone number. Name of Equipment Supplier Name Supplier Phone # 1 Home Health/Hospice Agency: Yes ; No ; Name: ; Phone #: ; Nurse: Yes ; No ; Physical therapy: Yes ; No ; Occupational Therapy: Yes ; No ; Speech Therapy: Yes ; No ; Aide: Yes ; No 1 Recent Hospitalizations: Please list hospitalizations in the past 2 years. Reason for Hospitalization Name of Hospital Date 1 Recent Doctors: Please list any recent doctors, their specialty (e.g. Primary doctor, cardiologist, neurologist, etc.) and their phone number and fax number. Doctor Name Specialty Phone Fax Please fax this information to HomeCare Physicians office at or mail it (address on first page) prior to the first visit HCP; May reproduce for patient use. 5
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DEMOGRAPHICS Name: Date of Birth: Sex: Male Female Ethnicity (optional): Hispanic or Latino Not Hispanic or Latino Race (optional): White Black or African American Other: PREFERRED LANGUAGE Is English
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
Health History. Tests and Procedures: Test: Date: Location: Provider: Abnormal: Results/Notes: Monthly self breast exam. Last mammogram (female)
Comprehensive Cancer Center A Cancer Center Designated by the National Cancer Institute Please answer the following questions and bring this form to your first appointment at Rutgers Cancer Institute of
INITIAL PATIENT FORM
Patient : INITIAL PATIENT FORM Reason for your visit: Visit Date: Left CIRCLE AREA(S) OF CONCERN: Right TOP/BOTTOM OUTSIDE INSIDE Type of pain: Sharp Burning Soreness Tightness Stabbing Numbness Aching
John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care