Heart Attack & Stroke
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- Gladys Walton
- 5 years ago
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1 Name: Date: Date of birth: How did you find out about the practice? Your answers will give us a better understanding of your medical concerns and conditions. If you are uncomfortable with any questions, feel free not to answer them. Best estimates are fine; however, be specific whenever you can. Please contact family members if you need assistance completing the family history section. If you need more space, simply attach as many additional pages as you need. Thank you! How would you rate your current health? a Excellent a Good a Fair a Poor Current age: Weight : Height: Ethnicity: Waist measurement: Date of your last physical exam: Medications: Please list all prescription and non-prescription medications, vitamins, home remedies, and herbs. Medication/Supplements Dose (mg per pill, doses per day) Start date Reason Blood type Allergies or reactions to medicines: When was your most recent: ABI (ankle brachial index) Cholesterol screening Chest X-ray Lung function Colonoscopy Endoscopy (upper GI) Chest Xray Peripheral Vascular Disease test (ABI) EKG IMT Bone density test Flu vaccine Shingles vaccine Pneumovax Dental exam Eye exam Coronary CT Scan Lung function Colonoscopy Endoscopy (upper GI) Chest Xray Peripheral Vascular Disease test (ABI) Any other vascular test (Please specify) 507 S. Washington Suite #170 Spokane, WA Phone: (509) Fax: (509)
2 Personal medical history Please indicate whether you have had any of the following medical problems (Include dates to indicate when the problem occurred.) Heart Disease a Stroke a High Cholesterol a High blood Pressure a Pre-diabetes a Diabetes a Mini-Stroke or TIA a Atrial Fibrillation a Poor blood flow to extremities a Poor blood flow to intestines a Poor blood flow to kidneys a Aortic Aneurysm a Brain aneurysm a Bleeding/clotting problems a Blood transfusions a Anemia a High red blood cell count a Leukemia a Abnormal platelet count a Heart Arrhythmia a Heart Valve Problem a Rheumatoid Arthritis a Kidney disease a Kidney stones a Gallbladder stones a Pancreatic disease a Fatty liver a Lupus a Psoriasis a Sjögren s Syndrome a Autoimmune disorder a Periodontal Disease a Dental infections a Root Canal a Bleeding gums a Gout a Polycystic Ovaries a Thyroid problems a Depression a Suicide attempts a Anxiety/Panic Attacks a Migraine Headaches a Thin Bones/osteoporosis a Stomach Ulcers a Chronic Heartburn a Restless legs a Sleep disorder a Hormone imbalance a Toxin Exposure a Unexplained Nerve Problems a Cancer a Physical disability a Mental disability a Mental disability a Post-traumatic stress syndrome a Celiac Disease a Diverticulosis a Irritable Bowel Syndrome a Gluten Intolerance a Blood clot in legs a Hodgkin s Disease a History Hepatitis a Alcoholism a Drug use a History AIDS a 2
3 Have you ever been hospitalized for illness? a Yes a No If so, when and why: Surgical history Please list all other operations with the dates when they occurred. Social history Tobacco use Cigarettes: a Never a Quit: date you quit smoking a Current smoker: (packs per day) Other tobacco (check all answers that apply): a Pipe a Cigar a Chewing tobacco a e-cigarettes a Marijuana Number of years you ve used this tobacco Are you interested in quitting? a Yes a No Have you tried to quit in the past? a Yes a No How many times have you tried to quit? What methods have you tried? Are you exposed to second-hand smoke? a Yes a No If yes, for how long? Alcohol use Do you drink alcohol? a Yes a No If yes, how many drinks do you consume per week? Alcohol type Does your alcohol consumption have you or others concerned? a Yes a No Other concerns Caffeine intake Coffee cups/day Tea cups/day Sodas per day a Diet a Regular Chocolate ounces per day (Circle one.) a Dark a Light Do you drink energy drinks or take pills to stay awake? a Yes a No If yes, specify Decaffeinated products? a Yes a No If yes, specify / how much Weight Are you satisfied with your weight? a Yes a No What is your goal weight? When did you last weigh your goal weight? How long were you at that weight? 3
4 Exercise Do you exercise regularly? a Yes a No What kind of exercise? How long do you exercise in minutes? How often? If you do not exercise, why not? Do you have any limitations to your ability to exercise? Please explain Socioeconomics Occupation Employer Years of education/highest degree Marital status: a Single a Married a Divorced a Widowed Spouse/partner s name Who lives at home with you? How many children do you have? (Please provide names, gender, and ages.) Where were you born? Where did you grow up? Where do you live now and for how long? Oral Health: How many times per day do you brush your teeth? What type of toothbrush do you use? Do you floss regularly? a Yes a No How often? How often do you see your dentist? Do you ever have bleeding gums? a Yes a No Does your oral health concern you? a Yes a No If yes, why? Stress How would you classify your stress level at work? (Please check one) a Low a Medium a High How would you classify your stress level at home? a Low a Medium a High Do you often feel anxious, angry, irritated or rushed? a Yes a No How do you manage your stress? List ways for which you relax? Do you meditate daily? a Yes a No If yes, how? Do you perceive a lack of control of your environment? a Yes a No If yes, why? Diet How do you rate your diet? (Please check one) a Good a Fair a Poor Do you currently see a dietitian? a Yes a No If yes, how often? Name and contact: How many daily servings of the following do you have: Whole grains Nuts Water Vegetables Fruit Milk what % How many times a week do you consume the following items? Eggs Margarine Fish Dairy Products Chicken/Turkey Fried Foods Red Meat Processed foods Butter Going out to eat Do you have any food allergies or food sensitivities? a Yes a No If yes, please explain Please List ALL supplements: Are you satisfied with your weight? a Yes a No Do you have any specific weight goals? 4
5 History for Men: Do you have problems with erections? a Yes a No If yes, date of onset Do you have problems with sexual desire or sex drive a Yes a No If yes, date of onset Do you have problems with sexual satisfaction a Yes a No If yes, date of onset Do you have problems with decreased energy or decreased muscle strength a Yes a No If yes, date of onset History for women How many times have you been pregnant? How many deliveries? miscarriages? Please list any problems you have experienced with pregnancy or delivery: Do you have osteoporosis (bone loss)? a Yes a No osteopenia (bone thinning)? a Yes a No When was the first day of your most recent period? What was your age at your first period? Frequency of periods Length of each (Check one) a Regular a Irregular Menopause? a Yes a No Hysterectomy? a Yes a No When Ovaries removed? a Yes a No Do you have any history of gestational diabetes? a Yes a No High blood pressure or eclampsia with pregnancy? a Yes a No Did any of your children weigh more than eight pounds at birth? a Yes a No Do you have problems with sex drive? a Yes a No If yes, date of onset Do you have problems with sexual satisfaction? a Yes a No If yes, date of onset 5
6 Travel History: Any recent International Travel? a Yes a No If yes, What Countries and dates of stay Any illnesses during or post travel? Review of symptoms Please check any current problems you have on the list below. Constitutional: Fever/chills/sweats Unexplained weight loss/gain Brittle nails Dry skin Change in skin texture Change in hair texture Inability to stand heat Inability to stand cold Change in energy/increased weakness Excessive thirst or urination Swelling (Explain) Respiratory: Cough/wheeze Difficulty breathing Snoring Sleep apnea/cpap Frequent respiratory infections Eyes: Change in vision (Explain) Dry Eyes Frequent irritation History of retinal tear or hemorrhages Double vision Glaucoma (Treatment?) Cataracts (Surgery?) Gastrointestinal: Abdominal pain Blood in bowel movement Heartburn Nausea/vomiting Diarrhea/constipation Loss of appetite Weight loss Weight gain Neurological: Headaches Light-headedness Memory loss Loss of coordination Tingling, pain, or numbness in hands or feet Psychiatric: Problems with sleep Depression Panic attacks Mania Anxiety Anger issues Short temper or impatience Unusual feeling of doom Suicidal thoughts Hopelessness and constant worry Ear/Nose/Throat/Mouth: Difficulty hearing/ringing in your ears Hay fever/allergies Bleeding gums Dental Cavities Painful teeth or gums Bad breath Root canals Dental implants Cardiovascular: Chest pain/discomfort Palpitations (irregular heart beats) Swelling in feet or legs Varicose veins Pain in extremities with excercise Skin: Acanthosis nigricans (dark lines around neck or under arms) Skin tags Flattening of nail beds Creases in earlobes Frequent itching of skin Skin infections Genitourinary: Unusual frequency of urination Increased urination at night that interrupts sleep Blood in urine Blood/Lymphatic: Easy bruising/bleeding Unexplained lumps Unusual bleeding Unusually pale Unusual rudy appearance History of blood clots History of low platelet counts History of high platelet counts History of low white blood cell counts History of anemia Muscle/Skeletal: Chronic joint problem Back problems Neck problems Spine problems Muscle injuries Arthritis History of bone fractures History of torn or ruptured tendons Paralysis of any muscles Unusual muscle weakness Any muscle side effects from statins Any other symptoms? If so, please list them: 6
7 Family history Please indicate the current status of your immediate family members. Include if each person is alive or deceased; the person s age now or at time of death; if applicable, the cause of death; and any other relevant comments. Mother s mother Mother s father Father s mother Father s father Mother Father Sister Sister Sister Brother Brother Brother Daughter Daughter Daughter Son Son Son Please use this space to list any additional family members: 7
8 Please indicate with a check mark any family members who have had any of the following medical conditions: Medical condition Mom Dad Sister Brother Daughter Son Mom s mom Mom s dad Dad s mom Dad s Dad Mom s sister Mom s brother Dad s sister Dad s brother Heart attack Stroke Diabetes-Type 2 (adult onset) Alcoholism Anemia Aortic aneurysm Alzheimer s Arthritis Asthma Autoimmune disorder Bleeding problems Carotid artery disease Cancer Depression Diabetes-Type 1 (childhood onset) Other genetic disease High cholesterol (hyperlipidemia) High blood pressure (hypertension) Immunosuppressive disorders Kidney disease Osteoporosis Peripheral vascular disease Epilepsy (seizure disorder) Substance abuse Thyroid disorder Smoking Sleep apnea Polycystic overy Disease Coronary bypass Coronary stents Mini strokes Gum Disease Bad teeth 8
Heart Attack & Stroke
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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
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Last Name: First Name: Date Form Completed: Referring Physician: Address: City: Sex: Marital Status: Race: Age: Married Caucasian Single Male Divorced African American Hispanic
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E mail newsletters, reminders, statements, etc. Emergency Name: Phone: City: State: Zip: Home
New Patient Questionnaire
New Patient Questionnaire Welcome to Mass General/North Shore Cardiology. Please fill out the following questionnaire, answering each question to the best of your ability. The information will assist your
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
Surgical History Please list all operations and dates:
1 General Information *Please complete in blue or black ink only* Name: Date: Address: City: State: Zip Code: Date of Birth: Email: Telephone: (Cell) (Home) (Work) Referred by: Occupation: Primary Doctor:
PATIENT HISTORY FORM
PATIENT HISTORY FORM Date: Page 1 of 5 Last Name: First Name: Middle Initial: Referred By: Age: Primary Care Doctor: Please provide name(s) of other physician(s) that you have visited within the last year:
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
Name of Pa. tient: Last. First. per day) 50 mg. X-ray dye or. IV contract. Name (Last) (First) Address. City, state/ zip code
Division of Cardiology for the Academic Medical Center of the University of Texas Medical School at Houston NEW PATIENT HISTORY FORM Please complete and fax to 713-512-2245 Name of Pa tient: Last _ First
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
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) :
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:
Practice: Today s Date: Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E-mail newsletters, reminders, statements, etc. Address: City: State:
PATIENT QUESTIONNAIRE / ASSESSMENT
PATIENT QUESTIONNAIRE / ASSESSMENT Diabetes Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital Status:
CURRENT MEDICAL HISTORY
Patient name Please print, and check the appropriate items CURRENT MEDICAL HISTORY Date of birth Age Today s Date Who referred you? Family Physician Address of family physician Skim through entire form