Marcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)
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1 Marcelo Garzon HOM.DSHomMed.Bsc. (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 LEAVE A MESSAGE AT THIS NUMBER? YES NO Primary Care Provider (if not joining our Primary Care Practice)? Please list all physicians that you see. (Please include Mental Health Professionals) Name Address Specialty, or condition being treated Please List any complementary and/or alternative practitioners you see or have seen in the past (i.e. chiropractor, acupuncturist, naturopath, massage therapist, spiritual healer, etc.) Approximate s of Treatment Name of Therapist or Treatment Facility Type of Treatment Reason For Treatment Beneficial Experience? What Health Issues Do You Want To Focus On During This Visit? Current Medical Problems (e.g. diabetes, heart disease, hypertension, etc.)
2 Past Medical History: List any major past illnesses, hospitalizations (include year and date if known). Past Surgical History: List any past surgeries (date /year) Past Gyn/Obstetrical History: List any past pregnancies. Vaginal Births Miscarriage/ Still Birth Caesarian Section Pregnancy Terminations Abnormal PAP tests Other GN Procedures Family History: Have your close relatives (parent, brother or sister, child, grandparent) had the following? Yes No If yes, which relative Age at Diagnose Heart Attack, Angina Stroke High Blood Pressure High Cholesterol Diabetes Thyroid Disease Breast Cancer Other Cancer- What type? Kidney Disease Osteoporosis Rheumatoid Arthritis Asthma Mental Health Disorder Substance Abuse Pharmaceuticals and Supplements: Do you have Medication Allergies? YES NO if Yes, Please list: Medication Reaction Medication Reaction
3 Please List All Prescribed And Over-The-Counter Medications You Take Regularly. Please Include All Supplements, Vitamins Or Herbal Products Medicine/ Supplement including Frequency Medicine/ Supplement including Frequency Dose Dose Please Outline Your Use Of The Following, Past Or Present: Product Current Use? Quantity Per Quantity Per Past Use? Yes No Day Week Yes No Do You Have Concern About Your Usage? Do You Routinely Wear a Seat Belt? Yes No Preventive Health: Please Provide the s and Documentation When Possible. Pap/ Pelvic exam (Females) Tetanus Vaccine (Specify Td or Tdap) Mammogram (Females) Flu Vaccine Colonoscopy Pneumonia Vaccine Test of Stool For Blood (Stool Guaiac) Zoster (shingles) Vaccine Rectal Prostrate Exam (Males) Hepatitis A Prostate Specific Antigen (Males) Hepatitis B Bone Density (Dexa) MMR Eye Exam Gardasil (HPV Vaccine Cardiovascular Stress Test Other Trauma History: Have you ever been the victim of trauma or abuse (including sexual, emotional, physical abuse or neglect and /or being a victim of an accident, violent crime, or a natural disaster)? Yes No If YES, is this an active issue in your life that you would like to address while you are here? Yes No
4 Review of Symptoms: Please check no or yes for the following current symptoms (within past 3 months) GENERAL YES NO GASTROINTESTINAL YES NO Fever Diarrhea/ Constipation Sweats at Night Indigestion/ heartburn Hot flashes Nausea Temperature Intolerance Blood in stool Excessive Thirst GENITOURINARY Fatigue Pain or burning on urination Sleep Difficulties Frequent urination Daytime sleepiness Waking to urinate more than once Unplanned weight change Excessive urination SKIN Difficulty emptying bladder Rash Urinary incontinence New or changing moles Decreased sexual desire EYES Pain with intercourse Pain Sexually transmitted disease Redness Fertility issues Vision change MEN EAR, NOSE, THROAT Erectile dysfunction Hearing loss WOMEN Ringing in ears Heavy vaginal discharge Dizziness or vertigo Heavy menstrual bleeding Bleeding gums Painful menstrual periods Nosebleeds Irregular menstrual bleeding BREAST MUSCULOSKELETAL Breast pain Generalized or all-over pain Masses and lumps Joint pain Nipple discharge Stiffness Skin changes Joint swelling CARDIOVASCULAR Joint redness Chest Back or neck pain Heart murmur NEUROLOGICAL Irregular heart beat (palpitations) Abnormal gait (Trouble walking) Leg swelling or edema Falling PULMONARY Headaches severe/ or frequent Wheezing or shortness of breath Seizures Chronic cough Muscle weakness, TIA or stroke HEMATOPOIETIC Fainting or loss of consciousness Swollen lymph glands Localized numbness, tingling, neuropathy Blood clots PSYCHOLOGICAL Excessive bleeding Anemia Anxiety Depression Memory loss Mood swings
5 Movement, Exercise and Rest: What forms of exercise do you enjoy? Please describe your usual physical activity Activity How Often How Long Each Time How many hours of sleep do you usually get each night? Describe any issues you have with sleep? Nutrition: please list any food allergies or sensitivities: Foods Reaction Foods Reaction Please list everything you ate in the last 24 hours. Morning: Afternoon: Evening: Snacks: Do you currently or have you ever had a problem with weight or eating? Yes No if YES please describe: Are you comfortable with your relationship with food? Yes No Do you feel knowledgeable about your nutritional needs? Yes No Who prepares your meals? Personal and Professional Development: are you currently EMPLOYED / RETIRED / UNEMPLOYED WORKING AT HOME / CARE-TAKING / DISABLED indicate your occupation if applicable: Are you happy with your occupation? Yes No Why? Do you anticipate any work changes in the near future? Retirement, etc. Do you have a Racial / Cultural heritage that important to you? Relationship: Relationship status: If married or partnered, what is your relationship length? What are your living arrangements? Number of children and ages:
6 Are you sexually active? Yes No Are you happy with your sexual life? Which relationship(s) fulfill and /or empower you? Who or what drains your energy? Physical Environment: Do you have specific health concerns about your current home or environment (quality of air, water, etc.)? Have you had hazardous environmental or occupational exposures? If yes, please describe. Spirituality: What things or activities bring you your greatest joy and meaning? What inspires you? What things create the greatest challenge you? What makes you feel connected to the larger world? Describe your spiritual or religious practices if any (i.e. meditation, prayer, time in nature, worship attendance, etc.) If time and money were not an issue, describe the things you long to do in your life. Mind Body Connection: Rate the amount of stress in your life: None / A Little Bit / Moderate / Quite a Lot / Extreme How well do you manage stress? Not at All / A Little Bit / Moderate / Quite Well / Excellent What are your main sources of stress in life? (Personal, professional, financial etc. ) What Are Your Health Goals? What are your overall goals for improving your health and your life? Is there anything else that would be helpful for us to know about you?
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Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire Please complete this questionnaire before your scheduled appointment and bring this form with you the day of your visit. Patient
Welcome to the UCLA Center for East- West Medicine Primary Care
Instructions: Welcome to the UCLA Center for East- West Medicine Primary Care We ask a lot of questions because we really want to get to know you! Please take your time with the paper work and return it
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Patient First Name Patient Middle Initial Patient Last Name. Primary Care Physician Primary Care Physician Phone Pharmacy Name
NP Hagans Walk-In Clinic * 9135 Piscataway Rd. # 320 Clinton, MD 20735 * (240)-412-5093 (Office) Patient Information Patient First Patient Middle Initial Patient Last Sex Marital Status Date of Birth Social
ALLERGIES. If yes, please list the food and non-medication (i.e. latex) allergies and type of reaction you had: MEDICATIONS
Name: Birthdate: What is your main health concern today? Do you currently use tobacco? YES NO Have in the past? YES NO Year Quit If yes, what kind of tobacco?_number of years: Amount of tobacco per day:
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
INTEGRATIVE MEDICINE CONSULTATION INTAKE FORM. We look forward to working with you to achieve your optimal health and well- being!
University of Florida Physicians PO Box 100383 UF Health Integrative Medicine - Executive Health Gainesville, Fla 32610 (352) 265- WELL (352) 265-8263- fax INTEGRATIVE MEDICINE CONSULTATION INTAKE FORM
Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?
Your Name: Date of Birth: Age: Address: City/State/Zip: _ Phone (home): (mobile): (work): Email: Shall we add you to our e-newsletter? Y / N Your Employer: Employer Phone: Employer Address: Your Occupation:
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
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
Name: Date of Birth: Age: Address: City State Zip
Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us?