Academic Urologist at Erlanger
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- Ursula Gibbs
- 6 years ago
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1 Academic Urologist at Erlanger Erlanger East Office 1755 Gunbarrel Road, Ste 209 Chattanooga, TN Erlanger Main Campus 979 E 3rd St Ste C535 Chattanooaga, TN PATIENT REGISTRATION FORM Spring Creek Office 961 Spring Creek Rd, Ste 202 Chattanooga, TN Today s date: Primary Care Physician: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Dr. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Street address: City: State: ZIP Code: Social Security no.: Home phone no.: Cell phone no.: ( ) ( ) Birth date: Age: Sex: Pharmacy Name: Street your pharmacy is on: / / M F Occupation: Employer: Employer phone no.: ( ) Do you have a living will? Yes No Address: Do you have power of attorney? Yes No If yes, person s name: Phone Number: Referred by (please check one box): Dr. Insurance Provider Hospital Family Friend Website/Internet Search Yellow Pages Other Spouse s Name (if applicable): Spouse s Date of Birth: INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Name of primary insurance: Group no.: Policy no.: Policy Holder s Name: Birth date: Policy Holder s S.S. no.: Employer: / / Patient s relationship to policy holder: Self Spouse Child Other Name of secondary insurance (if applicable): Group no.: Policy no.: Policy Holder s Name: Birth date: Policy Holder s S.S. no.: Employer: / / Patient s relationship to policy holder: Self Spouse Child Other Name and address of local friend or relative (not living at same address): IN CASE OF EMERGENCY Relationship to patient: Home phone no.: Work phone no.: ( ) ( )
2 Patient Information Patient s last name: First: Middle: Date of Birth: Today s Date: / / REASON FOR VISIT TODAY (Please describe your problem/reason for visit in detail): List Relevant Symptoms: Are you allergic to any medications? (If so please list or circle below) I have no known drug allergies Latex Shellfish X-ray Dye Iodine Are you on any medications? Please List: Are you taking any blood thinners? Aspirin Plavix Coumadin (Warfarin) Fish Oil Vitamin E Pradaxa Xeralto Do you smoke or use tobacco products? YES NO If yes, How many packs per day? For how many years? Do you drink alcoholic beverages? YES NO If yes, How many drinks per day? Do you drink caffeine (soda, coffee, etc.)? YES NO If yes, How many drinks per day?
3 Patient Information Patient s last name: First: Middle: Date of Birth: PATIENT PAST MEDICAL HISTORY: (Please list any medical conditions either current or past) Heart Disease Heart Attack Stroke Diabetes On Insulin? YES NO Cancer (Please specify type) Hypertension (High Blood Pressure) High Cholesterol Prostate Cancer Depression Kidney Stones Kidney Disease Dialysis HIV/AIDS Parkinson s Alzheimer s Hepatitis A / B / C Liver Disease Epilepsy or Seizures Other: PATIENT SURGICAL HISTORY: (Please list any surgeries you have had and the year they were performed) Name of Surgery Date of Surgery (Year) FAMILY MEDICAL HISTORY: (Please list any medical conditions in your family and specify which family member) CONDITION FAMILY MEMBER (mother, father etc) CONDITION FAMILY MEMBER (mother, father etc) Heart Disease Prostate Cancer Diabetes Cancer Type- Stroke High Cholesterol Alzheimer s Parkinson s Heart Attack Kidney Disease High Blood Pressure Dementia Other:
4 Patient Information Patient s last name: First: Middle: Date of Birth: Review of Systems Have you had any of the following problems recently? GENERAL: Weight loss or gain Fatigue Sleep Apnea Fever or chills Headaches Other: EYES: Blurry or double vision Glaucoma Cataracts NEUROLOGICAL: Dizziness Numbness/Tingling Seizures Fainting Tremors Paralysis/ Weakness ENDOCRINE: Excessive Thirst Tired/Sluggish Too Hot/Cold GASTROINTESTINAL: Abdominal Pain Nausea/Vomiting Stomach Ulcer CARDIOVASCULAR: Heart Trouble Chest pain or discomfort Heart Murmur High Blood Pressure Shortness of Breath Irregular Heart Beat SKIN: Rash Skin Lumps Psoriasis MUSCULOSKELETAL: Muscle or joint pain Back Pain Arthritis EAR/NOSE/THROAT/MOUTH: Sinus Problems Vertigo Hearing loss RESPIRATORY: Shortness of Breath Frequent Cough Tuberculosis Asthma Coughing up blood Wheezing HEMATOLOGICAL/LYMPHATIC: Swollen Glands Blood Clotting Problems HIV PSYCHOLOGIC: Depression Anxiety Suicidal Thoughts FEMALE PREGNANCY HISTORY: Number of Vaginal Deliveries Number of Caesarians
5 ABOUT OAB Think You Have Overactive Bladder? Do you think you have Overactive Bladder? Millions of men and women live with Overactive Bladder. This quiz will help you measure which Overactive Bladder (OAB) symptoms you have and how severe those symptoms are. Base your answers on the past month. (Circle the response that best answers each question) Symptom Questions Not at all Occasionally About once a day About three times a day About half the time Almost always SCORE 1. Urgency How often do you have a strong, sudden urge to urinate that makes you fear you will leak urine if you can t get to a bathroom immediately? 2. Urgency Incontinence How often do you leak urine after feeling an urge to go? (whether you wear pads/ protection or not) 0* Urology Care Foundation, Inc. 3. Incontinence How much urine do you think usually leaks? (whether you wear pads/ protection or not) 4. Frequency How often do you urinate during the day? 5. Wake to urinate How many times do you usually get up each night to urinate, from when you went to bed until you got up in the morning? None Drops 1 Teaspoon 1 Tablespoon ¼ cup Entire bladder 1-6 times 7-8 times 9-10 times times times 15 or more times None 1 time 2 times 3 times 4 times 5 times or more TOTAL SYMPTOM SCORE (Add score from questions ) = 0 = no symptoms 25 = most severe symptoms *If you score 0 on question 1, you probably don t have OAB.
6 (Circle the response that best answers each question) ABOUT OAB Quality of Life Questions How much does this bother you: I am not at all I am a great deal 1b. Urgency a strong, sudden urge to urinate that makes you fear you will leak urine if you can t get to a bathroom immediately? 2b. Urgency Incontinence leaking after feeling an urge to go? 3b. Frequency urinating frequently 4b. Waking from sleep to urinate? I would not be at all I would be a great deal 5b. Overall satisfaction If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? 6b. How have your symptoms changed your life? Please let us know how your symptoms (urgency, frequency, urine leakage, and waking at night) have changed your life. Are your symptoms: (Please check all that apply) r Keeping you from getting a good night s sleep? r Causing you to stay home more than you would like? r Keeping you from social activities or entertainment (movies, concerts, etc.)? r Causing you to exercise (walking, sports, etc.) less or limit your physical activity? r Causing problems with friends or loved ones r Keeping you from traveling, taking trips, or using public transit? r Making you plan trips around your knowledge of public restrooms? r Causing problems at work? r Other ways your symptoms have changed your life: 2012 Urology Care Foundation, Inc. Score the bother questions (1b, 2b, 3b, 4b, 5b & 6b) separately. Do not add them together. Even if you have mild symptoms, if they bother you enough to change your life, you and your healthcare professional should discuss what treatment options are available to you.
7 Instructions How do I use this Quiz? ABOUT OAB Read this list of questions and answer them. Then bring your completed quiz to your next visit with your healthcare professional. This can be an easy way to start talking about your symptoms. The questions will help measure which Overactive Bladder (OAB) symptoms you have and how much your symptoms bother you. The better your healthcare professional knows the level and impact of your symptoms, the better he or she can help you manage them. Scoring What do my results mean? For Symptom Questions (1 through 5): Add to get a score from 0 (no symptoms) to 25 (most severe symptoms). What your total Symptom score means: The higher your score for questions 1-5 are, the more severe your OAB symptoms are. However, if your score for question 1 is 0, then you do not have the hallmark symptom of Overactive Bladder strong sudden urges to urinate that you cannot ignore. The answers to the Symptom questions can help you and your healthcare professional understand which of your OAB symptoms are most severe. For Quality of Life Questions (1b, 2b, 3b, 4b, 5b, & 6b): DO NOT add your Quality of Life scores together. Each Quality of Life question is scored separately. What your Quality of Life results mean: Questions 1b, 2b, 3b, 4b, 5b, & 6b on this quiz help show how your symptoms impact your life. We hope this will help you start a discussion with your healthcare professional about your symptoms. Seeing how much your symptoms have changed your life can help your healthcare professional decide what treatment choices to offer. Even if you have mild symptoms, if they bother you enough to change your life, you and your healthcare professional should discuss what treatment options are available to you. What if I have other symptoms? Please let your healthcare professional know about any other symptoms you may have. (For example, do you have urine leakage when sneezing or exercising? Do you have bladder pain? Do you have to strain to begin urinating?) This will help your healthcare professional figure out if your symptoms could be caused by something other than OAB. It will also help them offer the treatment choices that are best for you Urology Care Foundation, Inc. Where can I find a healthcare professional? If you need a healthcare professional, visit to find a urologist near you. Chose incontinence as a special interest area to find urologists who said they are interested in helping patients who leak urine or have OAB. ItsTimeToTalkAboutOAB.org For more information, contact: Urology Care Foundation 1000 Corporate Blvd., Linthicum, Maryland , UrologyHealth.org Patient resources provided through the generous support of
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CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY REGISTRATION PAGE Date: Name: Tel: 510-526-5256 (Albany) 415-334-1010 (San Francisco) Fax: 510-526-5547 christopherbrowndo@gmail.com DOB: Age: Sex: Address:
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
THE OB/GYN CENTRE NEW PATIENT HISTORY
PERSONAL PROFILE NAME: AGE: NAME YOU WOULD LIKE US TO USE: OCCUPATION: MARITAL STATUS: GYNECOLOGICAL HISTORY LAST MENSTRUAL PERIOD (FIRST DAY): AGE PERIOD BEGAN: PRESENT BIRTH CONTROL PAST METHODS OF BIRTH
IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM.
Dr. Doug Scherr Date of Birth: Date: CHIEF COMPLAINT What is the main reason for your visit today? ALLERGIES Are you allergic to any of the following? Please check YES or NO for each. Check here if you
Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Circle Preferred Phone Number Home
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
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.
FOLSOM CARDIOLOGY. Registration Form. Office Use Only: Patient Acct #
FOLSOM CARDIOLOGY Please complete forms in black ink only Registration Form Office Use Only: Patient Acct # Name: Date of Birth: Address: Street City State Zip Code Phone: Work: Cell: Marital Status: S
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
Please review the below items in preparation for your visit.
2001 Santa Monica Blvd., Suite #760W Santa Monica, CA 90404 (310) 582-7474 (Office) (310) 582-7481 (Fax) http://california.providence.org/saint-johns/services/orthopedics/ http://www.totaljoints.net/ Dear
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
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:
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
medical questionnaire Date: Day Month Year
medical questionnaire Date: Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you
Mercy MS Center New Patient Information
Mercy MS Center New Patient Information Last Name: First Name: DOB: MULTIPLE SCLEROSIS HISTORY Reason for clinic visit: I have been diagnosed with MS or NMO (Date diagnosed ) I have not been diagnosed
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
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 These questions are general screening questions designed to identify areas where additional attention may be required. Please bring
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work)