STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit.
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1 PATIENT HEALTH HISTORY FORM DIRECTIONS AND VISIT DAY INSTRUCTIONS Prior to your Appointment: STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit. STEP 2: Labs Please have your labs drawn at least one week prior to your appointment if you would like to discuss your results at that time of you visit PLEASE FAST for 12 hours before your labs. ~ Enclosed you will find your lab order which can be done prior to your visit. *Note: Labs for Wellness Exam can ONLY be drawn at the QUEST DIAGNOSTICS, Philadelphia, PA, Hours are: Mon-Fri: 7:00am 3:30pm **Office is closed for Lunch from 12:00 pm 1:00 pm** MDVIP Membership Fee includes the cost of the labs. **If you take this lab slip to any other lab you WILL be charged an out of pocket fee. STEP 3: (optional) MDVIP Patient Portal ~ Available on the MDVIP portal is the Interactive Health Assessment that is a tool that will help you identify your health risks. If you do not have a username & password and would like one, please contact: MDVIP Corporate at or connect.mdvip.com/requestregistration-key On the Day of your Appointment: Please do not wear any perfumes, lotions or oils, since they may interfere with an ECG tracing. * Ph: (215) * Fax: (215)
2 Established Patient Forms Please complete these forms in advance of your appointment and bring them with you. Thank You. Name: DOB: Date: Please complete these forms in advance of your appointment and bring them with you. Thank You. What problems do you wish to discuss with the doctor during your evaluation today? Do you have an Advance Directive? Yes / No Please list any NEW allergies to medications: Drug / Reaction Surgical History: Please list any surgeries from the last year Date
3 In the last few weeks have you had problems with any of the following? Falls: Fatigue: Chest Pain: Sortness of Breath: Palpitations: Leg Swelling: Rash : Nasal Congestion: Sore Throat: Hearing Loss: Post Nasal Drip: Dizziness: Abdominal Pain: Nausea: Vomiting: Heart Burn: Indigestion: Diarrhea: Constipation: Change in Bowel Habits: Blood in Stool: Hemorrhoids: Bleeding Problems: Clotting Problems: Joint Pain: Back Pain: Headache: Tingling/Numbness: Sleep Problems: Visual Changes: Memory Loss: Anxiety: Sleep Disturbances: Urinary Frequency: Urinary Urgency: Blood in Urine: Urinary Incontinence: Kidney Stones:
4 Social History Please answer the following questions. What is your Marital Status? () Single () Married () Partnered () Divorced/ Separated () Widowed How many people in household? () 1 () 2 () 3 () 4 ()5+ Highest education level? Do you use recreational drugs? Are there guns in your home? Do you have a working smoke detector at home? Do you exercise? () High School () College () Graduate () Never () Occasional () 1-2 Days a week () 3+ Days a week Any questions about sex that you would like to discuss with the doctor? Do you have regular eye care? Do you have regular dental cleanings? Are you on a special diet? Have you ve been a victim of abuse? How is life in general? () Disastrous () Fair () Good () Very Good () Excellent
5 Burns Checklist ~ PHQ-9 Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use "x" to indicate your answer) ~ 0 ~ Not at all ~ 1 ~ Several days ~ 2 ~ M ore than half the days ~ 3 ~ Nearly every day 1) Little interest or pleasure in doing things 2) Feeling down, depressed or hopeless 3) Trouble falling or staying asleep, or sleeping too much 4) Feeling tired or having little energy 5) Poor appetite or overeating 6) Feeling bad about yourself or feeling that you are a failure or that you have let yourself or your family down 7) Trouble concentrating on things such as reading or watching TV 8) Moving or speaking so slowly that other people could have noticed or being so fidgety or restless that you have been moving around a lot more than usual 9) Thoughts that you would be better dead or that you want to hurt yourself in some way Beck Index How much you have been bothered by each symptom in the past week, including today. ~ 0 ~ None Not at all ~ 1 ~ Mildly Didn't bother me much ~ 2 ~ Moderately Unpleasent, but could stand it ~ 3 ~ Severely Could barely stand it Numbness or tingling Feeling hot Wobbliness in legs Unable to relax Fear of the worst happening Dizzy or lightheaded Heart pounding or racing Unsteady Terrified Nervous Feelings of choking Hands trembling Shaky Fear of losing control Difficulty breathing Fear of dying Scared Indigestion or discomfort in abdomen Faint Face flushed Sweating (not due to heat)
6 The CAGE and CAGE-AID Questionnaire Do you drink alcohol? Have you ever experimented with drugs? In the last three months, have you felt you should cut down or stop drinking or using drugs? In the last three months, has anyone annoyed you or gotten on your nerves by telling you to cut down or stop drinking or using drugs? In the last three months, have you felt guilty or bad about how much you drink or use drugs? In the last three months, have you been waking up wanting to have an alcoholic drink or use drugs?
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VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading