Initial Consultation

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Gordon Bradford
5 years ago
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Name: (Last) (First) DOB : (m/d/y) Sex: Male Female Social Security: - - Marital Status: Single Married Divorced Widowed Partnered Primary Care Physician: Mailing Address:

1 Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention on your first visit. Name: (Last) (First) DOB : (m/d/y) Sex: Male Female Social Security: - - Marital Status: Single Married Divorced Widowed Partnered Primary Care Physician: Mailing Address: Street Date of Last Physical Exam: Apt# City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Occupation: Employer: Emergency Contact: Emergency Contact Phone: May we know who referred you to us? What are your health concerns that you would like us to address? 1) 2) 3) 4) 5) Page 1 of 10

2 Check ALL that apply. Weight Gain Night Sweats Weight Loss Feeling Hot Fever Chills Fatigue Malaise Blurred Vision Eye Pain Dry Eyes Itchy Eyes Red Eyes Dry Mouth Mouth Ulcers Bleeding Gum Sore Throat Sinus Pain Hoarseness Jaw Pain Nasal Congestion Bruxism Ear Pain Nose Bleed Loss of Smell Vertigo Cough Sputum Wheezing Pleuritic Pain Shortness of Breath Chest Pain Palpitation Leg Swelling Nausea Vomiting Diarrhea Constipation Heartburn Bloating Abdominal Pain Loss of Appetite Rectal Bleeding Painful Urination Frequent Urination Incontinence Headaches Dizziness Joint pain Muscle Pain Backache Rash Hair Loss Brittle Nails Memory Loss Anxiety Depression Poor Sex drive Snoring Excessive Thirst Page 2 of 10

3 Personal Medical History Alcoholism Allergies Alzheimer s Anemia Angina Anxiety Arthritis Asthma Birth Defects Blood Disorders Cancer Chronic Fatigue Colitis Concussion COPD Depression Diabetes Diverticulitis Eczema Endometriosis Epilepsy Frequent Infections Fibromyalgia Gastritis Genetic Disease Gonorrhea Gout Hay Fever Heart Attack Hepatitis Herpes High Cholesterol High Blood Pressure Hyperthyroidism Hypothyroidism HIV/AIDS Infertility Insomnia Irritable Bowel Jaundice Kidney Disease Kidney Stones Lyme s disease Meningitis Migraine Headaches Multiple Sclerosis Narcolepsy Nervous Breakdown Neuritis Osteoporosis Obesity Panic Disorder Peptic Ulcer Pleurisy Pneumonia Prostate Problems Psoriasis Pulmonary Embolism Rheumatism Sinusitis Stroke Thromboembolism Tuberculosis UTI Family History Disease Father Mother Maternal Grandparent Alcoholism Allergies Alzheimer s Asthma Asthma Cancer COPD Depression Diabetes Heart Disease Hypertension Kidney Disease Osteoporosis Stroke Age of Death Cause of Death Paternal Grandparent Siblings Children Page 3 of 10

4 Surgical History Appendix Bariatric Cardiac Bypass Cardiac Catheterization Gall Bladder Hysterectomy Joint Replacement Sinus Surgery Surgical History Tonsils Hernia Repair Other : Allergies: 1) Do have any Drug Allergies? YES NO If yes, please describe: 2) Do have any Food Allergies? YES NO If yes, please describe: 3) Do have any Environmental Allergies? YES NO If yes, please describe: Preventive Screening Update Test Year Result Cardiac Stress Test Cholesterol Colonoscopy DEXA/Bone Scan Eye Exam Fasting Blood Sugar Men Only: Rectal Exam Men Only: PSA Men Only: Testosterone Women Only: Mammogram Women Only: Pap Smear Women Only: Menopause Page 4 of 10

5 Medication List: Please list all the medications you are taking Name Year started Dose How many times a day? Page 5 of 10

6 Supplements: Please list any supplements or remedies that you are currently using. Name Dosage Times per day Manufacturer Why you take it? Have you had any hospitalizations? List any Complementary Experiences that you have had before? Tobacco smoking: Yes No If yes then how many years? How many cigarettes per day? Are you still smoking: Yes No If no then when did you quit? Second hand smoke exposure in childhood? Yes No Page 6 of 10

7 Alcohol: Yes No If yes then how many years? How many drinks per week? Drugs: Yes No If yes then please list How do you describe your health? (Excellent, Good, Fair, Poor). And why? Who do you live with at home? Please describe people and pets. Do you like or dislike your occupation? Describe why? Describe any volunteer activities that you are involved in on regular basis. What are your hobbies? Page 7 of 10

8 How many times per week do you exercise? What exercises do you do? And what is the average duration? Do you have life stressors? If yes, please describe them and how they are impacting your lifestyle? What steps do you take to relief stressful situation? Do you belong to an organized religion or spiritual group? Do you have any concern regarding your sexual function or sexuality? Are you satisfied with your sleep? Page 8 of 10

9 Do you snore? Yes No Do you take any OTC medications to fall asleep? What is your typical day like? Page 9 of 10

10 Food Diary: What do you usually eat in breakfast? What do you eat in Lunch? What do you eat in Dinner? How many times a day do you snack? List your snacks including condiments: List beverages consumed per day and quantity (Coffee, teas, sodas, juices, drinks with artificial sweeteners) Page 10 of 10

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GoPrivateMD General Information & History Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.