SINAN DUZYUREK, MD, PLLC
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- Sylvia Harvey
- 6 years ago
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1 PATIENT INTAKE FORM- CLINICAL INFO SECTION Your Name: Today s Date: Reasons for Seeking Professional Evaluation and/or Treatment During your session today Dr. Duzyurek will be conducting a diagnostic interview and exam with you in order to identify symptoms, syndromes, or other issues that may benefit from the professional services he provides, as well as those issues that may require a referral. In order to help make this process more productive, please briefly state below in your own words the main reasons for making this initial appointment. In other words, in a nut shell (in a paragraph or two), describe the main current issues, symptoms, questions or areas of concern that have prompted this appointment. You may indicate the higher priority issues with an asterix. Also, if applicable, indicate the reason for seeing Dr. Duzyurek now, as opposed to an earlier point in the past; in other words, why now? ARE YOU ALLERGIC TO ANY DRUG(S) or OTHER THINGS? Yes ; if YES, to what? WHAT IS YOUR HEIGHT?: YOUR WEIGHT: Do Not Know 1
2 Current Treatment: Are you currently on any medications or in some form of therapy with someone? If so, please indicate below the names and dosages of current medications, and for how long you ve been on them. Also, if applicable, state the name and contact info of the doctor or therapist, and for how long and with what frequency you have been seeing him/her. You may also include other things you have tried on your own to help with your problem, and how they worked for you. PAST MEDICATIONS Please list in the space below all prescription medications you took or tried in the past, if any, and the reason they were discontinued: Have you had any diagnostic tests (blood tests, etc.) done in the last 12 mo? Yes If, Yes what did those tests entail (if known): HOW LONG AGO WAS YOUR LAST EJACULATION VIA ANY MEANS (SUCH AS INTERCOURSE, ORAL SEX, HANDJOB, OR MASTURBATION)? HOURS/DAYS/WEEKS/MONTHS AGO RATE THE QUALITY OF YOUR MOST RECENT ERECTION (HARDON): Very Firm and well-sustained Quite firm and well-sustained Hard enough for penetration but not adequately rigid Good hardness first, but then lost Barely enough hardening to do anything with it Enlarged but Not hard enough to do anything enjoyable with it Not even enlarged Other 2
3 PERSONAL MEDICAL HISTORY Please Check the Corresponding Box Below to Indicate Any Physical Health Conditions You Have Had: History of Seizures/Convulsions/Fits/Epilepsy History of Head Trauma History of Stroke History of Brain Surgery Diabetes High Blood Pressure Heart Disease Liver Disease Kidney Disease Skin Disease Hypothyroidism Hyperthyroidism Sex Hormone Problem Other Hormonal (Endocrine) Disorder HIV Infection AIDS Deafness or Hearing Loss Glaucoma Vision Problem (not corrected by lenses or Lasik) Stomach/Duodenal Ulcers Irritable Bowel Syndrome Other Gastrointestinal Disorder Tuberculosis Lyme s Disease Sexually Transmitted Disease Other Infectious Illness Gynecological Condition Acid Reflux Disease Asthma Other Lung Disease High Cholesterol or Other Blood Lipid Disorder Gout Lupus Other Systemic Autoimmune Disorder Multiple Sclerosis Parkinson s Disease Migraine Other Headache Condition Fibromyalgia Other Chronic Pain Condition Anemia Other Blood Disorder Arthritis Other Rheumatologic Condition Overweight or Obesity Underweight Loss of Appetite for Sex Difficulty with Orgasm Erectile Disorder Other Sexual Dysfunction Any Unremovable Metalic Object in Your Head Any Implanted Object or Device in Your Body A Prostate Problem Other Male Sex Organ (Penis / Testis) Issue Other Condition(s): No specific medical problem (except minor ones like common cold) to report in the past or currently IMPORTANT: At this point, please go over the list above and indicate the condition(s) that have been professionally diagnosed with a D and those that are only your self-report with an S. Also indicate those that are currently active requiring ongoing monitoring or management with an asterix (*) Please provide pertinent specifics on your physical health history (do not include medications here): 3
4 REVIEW OF SYSTEMS Name: Today s Date: The following is a screening of any CURRENT symptoms you may be experiencing today and within the last 7 days in various body systems. This screening is necessary for an integrated evaluation of your health status and its documentation is required for this visit to be eligible for insurance coverage. In each area, if you are not having any difficulties, please check No Problems. If you are currently experiencing any of the symptoms listed, PLEASE CIRCLE THE ONES THAT APPLY, or explain any that may not be listed. If you have any questions about this, please ask one of the staff members, or your doctor. Constitutional (Health in General) No Problems Lack of energy, unexplained weight gain or weight loss, loss of appetite, fever, night sweats, pain in jaws when eating, scalp tenderness, prior diagnosis of cancer. Other: Ears, Nose, Mouth & Throat No Problems Difficulty with hearing, sinus problems, runny nose, postnasal drip, ringing in ears, mouth sores, loose teeth, ear pain, nosebleeds, sore throat, facial pain or numbness. Other: C-V (Heart & Blood Vessels) No Problems Irregular heartbeat, racing heart, chest pains, swelling of feet or legs, pain in legs with walking. Other: Resp. (Lungs & Breathing) No Problems Shortness of breath, night sweats, prolonged cough, wheezing, sputum production, prior tuberculosis, pleurisy, oxygen at home, coughing up blood, abnormal chest x-ray. Other: GI (Stomach & Intestines) No Problems Heartburn, constipation, intolerance to certain foods, diarrhea, abdominal pain, difficulty swallowing, nausea, vomiting, blood in stools, unexplained change in bowel habits, incontinence. Other: Genitourinary No Problems Painful urination, frequent urination, urgency, prostate problems, bladder problems, erection/ejaculation problems, lump or pain in testes, sore or discharge in the genital area, painful or abnormal menstruation, painful intercourse Other: MS (Muscles, Bones, Joints) No Problems Joint pain, aching muscles, shoulder pain, swelling of joints, joint deformities, back pain. Other: Integ. (Skin, Hair & Breast) No Problems Persistent rash, itching, new skin lesion, change in existing skin lesion, hair loss or increase, breast changes. Other: Neurologic (Brain & Nerves) No Problems Frequent headaches, double vision, weakness, change in sensation, problems with walking or balance, dizziness, vertigo, tremor, loss of consciousness, seizures, uncontrolled motions, episodes of visual loss. Other: Psychiatric (Mood & Thinking) No Problems Insomnia, irritability, depression, anxiety, recurrent bad thoughts, suicidality, mood swings, paranoia, hallucinations, compulsions. Other: Endocrinologic (Glands) No Problems Intolerance to heat or cold, menstrual irregularities, frequent hunger/urination/thirst, changes in sex drive. Other: Hematologic (Blood/Lymph) No Problems Easy bleeding, easy bruising, anemia, abnormal blood tests, leukemia, unexplained swollen areas. Other: Allergic/Immunologic No Problems Seasonal allergies, hay fever symptoms, itching, frequent infections, exposure to HIV, immune deficiency Other: 4
5 Over the Counter Drugs, Supplements, or Devices: Please list below any non-prescription drugs you are taking for treatment or prevention purposes. Include the name of the drug, strength, and the frequency (for example, once a day, twice a day, once at bed time, as needed ). Also include any over-the-counter devices, supplements, herbals, vitamins, etc. ALCOHOL or SUBSTANCE ABUSE or ADDICTION Recently (Within Last 3 Months), Have You Used Alcohol to Excess or in a Problem-Causing Way? Yes Recently (Within Last 3 Months), Have You Used Any Other Substance That Can Be Abused to Get High (or to escape from difficult feelings)? Yes In the Past, Have you had a Period with Problem or Excessive Drinking or Alcohol Dependence? Yes In the Past, Have You Had a Period with any other Substance Abuse or Addiction? Yes Past Emotional History: IN ADDITION TO THE CURRENT PROBLEMS OR ISSUES THAT PROMPTED THIS APPOINTMENT, HAVE YOU ALSO EXPERIENCED ANY PSYCHIATRIC (EMOTIONAL, PSYCHOLOGICAL) SYMPTOMS, DIFFICULTIES OR PROBLEMS IN THE PAST (Including Childhood)? PLEASE CHECK THE CORRESPONDING BOX IF YOU HAD ANY ONE OF THE FOLLOWING IN THE PAST? Mild Depression Moderate/Severe Depression Mild Mania (or Hypomania) Moderate/Severe Mania Panic Attacks Social Anxiety Over-Worrying/Generalized Anxiety Obsessive Compulsive Disorder Post-Traumatic Anxiety Disorder Other Anxiety issues A Sleep Disorder Irritability/Anger Issues Attention Deficit/Hyperactivity Disorder Paranoia Hallucinations Delusions Suicide Attempt Serious Thoughts of Suicide Deliberate Self-Harm (such as self-cutting) Psychosomatic Issues Problems Related to Excessive Alcohol Use (Problem Drinking) Other Substance Abuse or Dependence Relationship Difficulties An Eating Disorder Sexual Function Difficulty Other (please specifiy: ) 5
6 INTIMATE RELATIONSHIP HISTORY On a timeline, please briefly summarize your history of romantic and/or sexual relationships or pursuits, such as experimenting, dating experiences, short- and long-term relationships, marriages, divorces. You may also briefly mention any outstanding events, accomplishments, challenges, setbacks, and difficulties. HISTORY OF BEING SUBJECTED TO ANY KIND OF ABUSE At any point in your life, have you suffered any physical, emotional or sexual abuse? Yes If No, skip this section. If Yes, provide a brief summary of the specifics (including, in what way, at what age or during what period of time, by whom, and whether you received any professional help, etc) 6
7 FAMILY HISTORY OF MEDICAL or PSYCHIATRIC CONDITIONS Among your biological relatives have there been any individuals with current or past known or suspected medical illnesses or psychiatric difficulties, for example, depression, bipolar disorder, an anxiety disorder, OCD, ADHD, alcohol or substance abuse or addiction, suicide, epilepsy, cancer, diabetes, heart disease, hypertension, sexual dysfunction, etc? Diagnosed and treated professionally? Have they been on any medications? If so, the name of the medication(s), if you can. Please start with first-degree relatives (parents, siblings and children), then grandparents, and then other blood relatives such as cousins, aunts, uncles, nieces / nephews, etc. Is There Any Other Relevant Information Regarding Your Past or Family History That You Would Like to Include? Yes If Yes, please summarize here: 7
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Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
Women s and Men s Health Intake Form Comprehensive Physical Therapy Center
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Providence Medical Group
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Margie Petersen Breast Center
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Health Questionnaire
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Integrative Consult Patient Background Form
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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
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PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: SS#: - - Address: City, State, Zip Code Single( ) Married( ) Partner( ) Divorced( ) Widowed( ) Legally Separated( ) Male( ) Female(
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
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Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
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Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
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