NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVER S LICENSE NUMBER: STATE: ADDRESS:
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1 NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVER S LICENSE NUMBER: STATE: ADDRESS: MARITAL STATUS: ( ) SINGLE ( ) MARRIED ( ) DIVORCED ( ) WIDOWED ( ) SEPERATED ( ) UNDISCLOSED PATIENT S EMPLOYER: WORK #: BUSINESS ADDRESS: CITY: STATE: ZIP: EMPLOYER: WORK #: EMERGENCY CONTACT: PHONE: WHOM MAY WE THANK FOR REFERRING YOU: RELATIONSHIP TO PATIENT: DATE OF BIRTH: ADDRESS: CITY: STATE: CONTACT #: ( ) CELL ( ) HOME PATIENT SIGNATURE: DATE:
2 Occupation: Primary Care Doctor (PCP): Phone number: Pharmacy Number: Date of last physical exam: Personal Health History Please circle all that apply: General Diabetes Personal History of High Cholesterol Family History of Unwanted Weight Loss Autoimmune Disorder Cardiovascular Heart Failure Heart Attack Heart Murmur Vascular Disease Blood Clots Edema Congestive Heart Hypertension Irregular Heartbeat Failure Respiratory Sleep Apnea Shortness of Breath Asthma/ COPD Bronchitis Pneumonia Allergies Gastrointestina l Lactose Intolerance Gall Bladder Gall Stones Genitourinary Chronic Diarrhea Prostate Painful Urination Enlarged Prostate Chronic Constipation Prostate In Family Decreased Urinary Force Blood in Urine Overactive Bladder ON/OFF Urine Flow Kidney/Bladder History Infection Kidney/Bladder Liver Any other Psychiatric History of Depression Personality Disorder Any other
3 List your prescribed drugs and any over-the-counter drugs, such as vitamins and inhalers. Please make sure to include any anti-anxiety or antidepressant medications. Allergies: No Known Allergies or List Allergies and Reaction Surgeries: Year Surgery/Reason Year Surgery/Reason HEALTH HABITS AND PERSONAL SAFETY Exercise: Sedentary (No exercise) Mild exercise Occasional vigorous exercise Regular vigorous exercise Describe type of exercise and frequency (resistance training, cardiovascular, number of times per week)
4 Rate your quality of sleep: 1-Worst 10-Best Lifestyle Questionnaire Alcohol: Yes Number of drinks per week: No Tobacco: Yes Cigarettes Cigars Chewing How many/much: No Illicit drug use: Yes Explain No Vitals Blood Pressure Pulse Respiratory Rate Weight Height SYMPTOMS OF LOW TESTOSTERONE LEVELS Daytime sleepiness Yes No Decreased concentration Yes No Decreased energy Yes No Decreasing muscle mass Yes No Decreasing muscle strength Yes No Depression Yes No Difficulty learning things Yes No Diminished sex drive Yes No Erectile dysfunction Yes No Frequent joint/muscle pains Yes No Height decrease Yes No Increasing fatigue Yes No Memory loss Yes No
5 Moodiness Yes No Poor sleeping habits Yes No Trouble losing weight Yes No I have had testosterone checked previously Yes No I have used testosterone (prescribed or otherwise) or any other anabolic steroids in the past **Please be completely truthful with your response - it is critical in order to diagnose and prescribe correctly ** Yes No If yes, date(s): Type: Usage: I hereby also declare that I will not be attending or starting any military basic/advanced individual training (AIT) school while I am a patient of Axis Rejuvenation, LLC. Patient Name (Print) DOB: Signature: Date:
Premier Internal Medicine of Alpharetta, PC
Patient Information Date / / First Name Middle Initial Last Name Date of Birth / / Social Security # Gender Male Female Marital Status Single Married Separated Divorced Widowed Address Apt # City State
New Patient Paperwork
Name (Last, First, M.I.): M F Email Address: Primary Phone: Race: Today's Date: DOB: Alternate Emergency Phone: Contact: American Indian/Alaska Native Asian African American Caucasian Nat Hawaiian/Pacific
DANA COKER KINGDON, PA
PERSONAL HEALTH HISTORY AGNES KINRA, MD, PA Board Certified in Internal Medicine DANA COKER KINGDON, PA 4104 West 15 th St # 101 Plano, TX 75093 Phone 972-596-0006 Fax 972-596-0904 Name (Last, First, M.I.):
FAMILY MEDICINE New Patient Medical History Form
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New Patient Questionnaire
New Patient Questionnaire Date of appointment (MM/DD/YYY): Name (Last, First, MI): Previous Names: DOB (MM/DD/YYY): Phone: Cell: Email: May we email you with sensitive information, such as test results?
Name: Date of Birth: Street Address: Apt.# City: State: ZIPCODE: Home Phone: Work Phone: Cell Phone: Pharmacy name & address: Phone#:
Stephen L. Aronoff, M.D., F.A.C.E. Diplomate of the American Board of Internal Medicine and the Subspecialty Board of Endocrinology and Metabolism 2400 Lakeside Blvd., Suite 130, Richardson, TX 75082 Phone:
Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female
Place Patient Sticker Here Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female Social Security # Marital Status: Single Married Divorced Widowed Ethnicity: Non Hispanic
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
GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
GUPTA SPORTS & SPINE CENTER
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
Patient Data Sheet. Emergency Contact Name: Relationship: Contact phone number: Name: Specialty: Office address: Office phone: Fax:
Today s Date: / / Your Information Patient Data Sheet Last ame: First: MI: Sex: M F Date of Birth: / / Age: SS: Address: Home phone: Cell phone: Can we leave message on Home? Y or Cell? Y Are you currently
NEUROLOGICAL SURGERY, P.C.
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Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715
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Denise E. Bruner, M.D. & Associates, P.C.
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Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
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Adult Demographics Form
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Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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Seminar Information Page
OFFICE USE ONLY Height, Weight & BMI Insurance Primary Care Phys. Medical Problems Surgical History Med List & Dosage Allergies & Fam Hist. CDS (city, washoe, wcsd or reno diocese) OFFICE USE ONLY Pt #
WELCOME TO OUR OFFICE
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Male New Patient Questionnaire
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In case of emergency, please notify:
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PATIENT REGISTRATION
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CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
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Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction