Kantar Health NHWS Overview
|
|
|
- Liliana Daniels
- 6 years ago
- Views:
Transcription
1 Kantar Health NHWS Overview For more information, please contact:
2 What is the National Health and Wellness Survey (NHWS)? High view Journey through the system Holistic view of the patient that can only be captured from the patient 10 countries including emerging markets Consistent methods/measures Country-specific nuances Low view Attitudes, behaviours, characteristics and demographics The largest global selfreported general population survey Lifestyles and demographics Symptoms Self-rated severity Co-morbidities and risk factors Treatments adherence and satisfaction Quality of life and health utilities Work productivity Resource utilization Validated instruments Non-exclusive coverage (adults 18+) National projected values Latent populations including symptomatic undiagnosed and untreated
3 How NHWS is specific All patients, including undiagnosed symptomatic, but unaware (validated scales), untreated, OTC only, uninsured 165 conditions + risk factors including those not usually screened by physicians or reported by patients (e.g. alcohol consumption, ED, pain, ) Comprehensive patient-centric information, which provides a comprehensive overview of co-morbidities and granular segments Reliable unmet needs evaluation (e.g. burden of illness, adherence ) as information is provided directly from the patient with no physician bias International across 10 key geographies, consistent and comparable data across geographies Representative of the population = projectable Results immediately available
4 Representative of the population providing comparable results across countries APPROXIMATELY 260,000+ PARTICIPANTS ACROSS THE TEN COUNTRIES US 5EU Russia Japan Brazil A mixed method: online internet-based in the US and Japan and off-line recruitment in most other geographies to capture elderly population Representative of the adult population in each country; recent census info informs sample plan In Russia and China, representative of the urban population China target sample size
5 A wide range of metrics captured to help address your specific objectives Market Epidemiology Prevalence & Incidence Class of Treatment Trends Attitudes Behaviours Characteristics Demographics General Healthcare* Preferences* Physicians Compliance Brand level usage* OTC usage Office, Hosp. and ER visits Cost cutting strategies Source of Information Physician behavior Number of days used* Satisfaction* Co-morbidities Symptoms, Frequency & severity* Quality of life & WPAI Length of time diagnosed* Family history Prescription coverage & insurance Lifestyle considerations Basics: age, gender, income, educ. Body Mass Index *Indicates where data are captured in modules and not available to all respondents within a dataset
6 Broad Therapeutic Coverage 2016 Conditions HEART OR BLOOD Angina Arrhythmia Atherosclerosis Atrial fibrillation Deep Vein Thrombosis (DVT) Heart attack Heart murmur Hemophilia A or Hemophilia B High blood pressure (Hypertension) &/or Congestive Heart Failure High cholesterol Left ventricular hypertrophy (LVH) Baby aspirin / Low dose aspirin users Mini-Stroke/Transient Ischemia Attack (TIA) Peripheral arterial disease (PAD) Peripheral vascular disease (PVD) Pulmonary Embolism Stroke Type 1 Diabetes or Type 2 Diabetes Unstable Angina/Chest pains RESPIRATORY Chronic obstructive pulmonary disease (COPD), Chronic bronchitis, Emphysema Cystic Fibrosis Tuberculosis Allergies (Nasal) Asthma INFLAMMATION/IMMUNOLOGY/CHRONIC PAIN Ankylosing Spondylitis Osteoarthritis Psoriatic Arthritis Rheumatoid Arthritis Gout Lupus Osteopenia Osteoporosis Migraine PAIN Arthritis, Back, Lower Back, Lumbar Radiculopathy, Joint pain Bladder, Pelvic / Hip, Broken Bones, Joint, Neck Carpal Tunnel Syndrome, Cancer, Phantom Limb Pain Dental Problems, Menstrual Cycle Neuropathic, Post-herpetic Neuralgia, Diabetic Neuropathic Pain, Pinched nerve, Fibromyalgia Plantar Fasciitis, Headache, Migraine Ruptured/Herniated Disc, Sciatica Shoulder Pain/Shoulder Stiffness Sprains or Strains, Tendonitis Surgery or Medical Procedure, Spinal Disk EMOTIONAL OR MENTAL Bipolar disorder Schizophrenia Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) Depression Anxiety Generalized anxiety disorder (GAD) Obsessive Compulsive Disorder (OCD) Panic disorder Phobias Post-Traumatic Stress Disorder (PTSD) Social anxiety disorder SLEEP CONDITIONS Insomnia, Parasomnia, Narcolepsy, Circadian rhythm sleep disorder, Sleep Apnea/Sleep disorder breathing, Sleep difficulties (other than Insomnia, Narcolepsy or Sleep Apnea) LIVER Chronic liver disease Cirrhosis Non-Alcoholic Steatohepatitis (NASH) VACCINES Hepatitis A vaccine Hepatitis B vaccine Hepatitis A / Hepatitis B combination vaccine Human papilloma virus (HPV) vaccine f Measles, mumps, rubella (MMR) vaccine Meningococcal (meningitis vaccine) Pneumococcal (pneumonia vaccine) Seasonal Influenza (flu) vaccine Tetanus, diphtheria vaccine Varicella (chicken pox vaccine) Diphtheria, Dothienenteria Haemophilus Influenza, H Influenzae Tipo B Hexavalente, Hydrophobia Japanese Encephalitis Parotiditis, Pentavalent Pertussis Combination Poliomyelitis, Prostate Cancer Rotavírus Pentavalent Rubella, Shingles, Tick-borne Encephalitis, Tuberculosis, Yellow Fever Antibiotics, Growth Hormone CAREGIVERS Alzheimer's disease, Bipolar disorder Cancer Chronic Kidney disease on dialysis COPD, Heart Disease (such as Congestive Heart Failure), Dementia, Depression Diabetes (Type I), Epilepsy, ITP (platelet disorder), Macular Degeneration, Multiple Sclerosis, Muscular Dystrophy, Osteoarthritis Parkinson's Disease, Schizophrenia, Stroke DIGESTIVE C. difficile (antibiotic-associated colitis) Crohn s Disease Ulcerative Colitis Ulcers (active/peptic stomach or duodenal) Chronic constipation Diarrhea (frequent) Diverticulitis GERD or acid reflux Heartburn Irritable bowel syndrome (IBS) SKIN OR NAIL Psoriasis Rosacea Shingles Skin ulcers/cellulitis Acne Chronic Hives Atopic Dermatitis, Dermatitis, Eczema Fungal infections of the skin or Athlete s foot Shingles UROLOGY OR KIDNEY CONDITIONS BPH (benign prostatic hyperplasia), Chronic kidney disease Moderate or severe renal/kidney disease Overactive Bladder Dry Wet / Stress Urinary Incontinence Erectile dysfunction Urinary tract infection Yeast infection NEUROLOGICAL Dementia Epilepsy Hemiplegia Multiple Sclerosis Muscular Dystrophy Parkinson's disease Alzheimer s Disease Restless Legs Syndrome / Willis Ekbom Disease (WED) WOMEN S HEALTH CONDITIONS Endometriosis Fibroids Pregnancy, Pre-term labor Dysmenorrhea, Heavy menstrual bleeding Hot flashes, Menopause Pre-menstrual dysphoric disorder (PMDD) Pre-menstrual syndrome (PMS) Contraceptives, Tubal Ligation Hysterectomy INFECTIOUS DISEASES AIDS Genital herpes, Genital warts Hepatitis A, Hepatitis B, Hepatitis C HIV EAR, EYE, DENTAL Cataracts Dry Eye Glaucoma Macular degeneration (wet or dry) MEN'S HEALTH CONDITIONS Low testosterone Pre-mature ejaculation CANCER Any tumor, Breast cancer Cervical, Colorectal Leukemia, Lymphoma Metastatic solid tumor, skin cancer Non-Small Cell Lung, Small Cell Lung Ovarian, Uterine, Prostate, Other OTHER CONDITIONS Alcoholism Connective tissue disease ITP (Idiopathic thrombocytopenic purpura) Paget's disease, Sjögren's Syndrome Smoke cessation Thyroid condition Weight Loss / Obesity Anemia Gingivitis CAP (community-acquired pneumonia) HAP (hospital-acquired pneumonia)
How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all
Family Health History Please answer each question as honestly as possible. There are no right or wrong answers to nay of the questions. It is important that you answer as many questions as you can. We
EVIDENCE-BASED VITAMIN AND MINERAL USAGE SUMMARY TABLE (APRIL 2002)
Acne Acrodermatitis Enteropathica Adrenal Support Age Related Cognitive Decline Alcoholism/Alcohol Withdrawal Alzheimer's Disease Amenorrhoea Anaemia Angina Anorexia Nervosa Anxiety Asthma Atherosclerosis
SCHNEIDER MEDICAL GROUP, PA History Intake Form (Please Print)
History Intake Form Patient Name: Date of Visit: Briefly State the reason for the visit: Date of Birth: Physician Use Only - History and Present: 1. 2. 3. 4. 5. Page 1 of 10 Review of Symptoms HEAD NO
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Nutrition Consultation Intake Form Please write or print clearly
Artemis in the City, LLC Danielle Heard, MS, MS, HHC Clinical & Functional Nutritionist ph: 866-330-5421 fx: 212-535-3234 www.artemisinthecity.com Nutrition Consultation Intake Form Please write or print
SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2019
January 2019 DATE DAY TIME TOPICS TOTAL January 03 1. Alcoholism 2. Nutrition for the Elderly 3. Uterine Fibroids 4. HIPAA 5.Arthritis 6. Childhood Obesity January 10 1. Understanding Epilepsy: Latest
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed.
Name: SS# In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed. Patient Medical, Surgical and Family History Review
SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2018 WALK INS ARE ACCEPTED BUT WE ADVISE STUDENTS TO PRE-REGISTER BEFORE THURSDAY
SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs January 201 DATE DAY TIME TOPICS January 04 January 11 January 1 January 25 9:00AM 9:00AM 9:00AM 9:00AM 1. Understanding Fibromyalagia 2. Diabetes
New Patient Intake Form Pickering Chiropractic Health Centre 1154 Kingston Road Pickering ON, L1V 1B4
New Patient Intake Form Pickering Chiropractic Health Centre 1154 Kingston Road Pickering ON, L1V 1B4 Date: Name Age Date of Birth Address Postal Code Occupation Phone (home) (work) Okay to leave a message?
UnitedHealth Premium Physician Designation Program Episode Treatment Groups (ETG ) Description and Specialty
UnitedHealth Premium Physician Designation Program Episode Treatment Groups (ETG ) Description and Specialty 666700 Acne Family Medicine, Internal Medicine, Pediatrics 438300 Acute Bronchitis Allergy,
New Patient Paperwork
New Patient Paperwork Date: Phone: Patient: Last Name First Name Initial Street Address: City/State/Zip Code: Sex: M F Age: Birthdate: Single Married Widowed Separated Divorced Email: Newsletter? Y N Insured
SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2018
January 201 DATE DAY TIME TOPICS TOTAL January 04 1. Understanding Fibromyalagia 2. Diabetes and Cardiovascular Disease 3. Prostate Cancer 4. Hepatitis C 5. Understanding Hepatitis B January 11 1. Dysphagia
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Pharmacy Prep. Qualifying Pharmacy Review
Pharmacy Prep 2014 Misbah Biabani, Ph.D Director, Tips Review Centres 5460 Yonge St. Suites 209 & 210 Toronto ON M2N 6K7, Canada Luay Petros, R.Ph Pharmacy Manager, Wal-Mart, Canada 1 Disclaimer Your use
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
Premium Specialty: Pediatrics
Premium Specialty: Pediatrics Credentialed Specialties include: Adolescent Medicine, Pediatric Adolescent, and Pediatrics This document is designed to be used in conjunction with the UnitedHealth Premium
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
Clinic Adult Patient Demographics
Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) - May we leave
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
Evolve180 / Ideal Northwest Health Profile
Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Email: Date of Birth: Age: Height: Occupation: How did you find out about our program? Marital
CHRONIC TREATMENT GUIDELINES
CHRONIC TREATMENT GUIDELINES REGISTRATION OF CHRONIC CONDITIONS You can only access benefits for chronic medication, as listed below, if your prescribing/treating doctor or pharmacist registers your chronic
Primary Care Clinic Adult Patient Demographics
Primary Care Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) -
PERSONAL HISTORY CURRENT HEALTH CONDITION
PERSONAL HISTORY Name: Date S.S.# Address: City: State Zip code Home phone Cell Other: E-Mail Date of Birth Age Sex Male Female Business/Employer Address Type of Work Years Employed Check One Married Single
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.)
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.) TODAY'S DATE Your age DATE OF BIRTH YOUR NAME (Last) (First) (M.I.) REFERRED HERE BY YOUR PAST MEDICAL HISTORY (If YOU have
Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
Southwest Service Life Insurance Company
Southwest Service Life Insurance Company UNDERWRITING GUIDE 2/2012 95587v1Proof.indd 1 95587v1Proof.indd 2 95587v1Proof.indd 3 Acne A A A ADD A A A Addison s Disease D A D AIDS, ARC, HIV Infection D D
Women s Health. Allergies Medication, Food, or Substance (List below) What happens? (Symptoms or reactions) When did this occur?
For Office Use Only: HT: WT: B/P: / R: P: Age: Urine Results: Glu: Ket: Blood: Protein: Nitrites: Leuk: Your DaVita Medical Group medical record is becoming electronic. Help us enter accurate information
BREAKTHROUGH MEDICINE
Page1 BREAKTHROUGH MEDICINE SHAIDA SINA, NMD PRACTICE Patient Visit LOCATION: Location: 2530 W. ST. RT. 89A, Suite B1 Core Chiropractic Sedona, AZ 86336 2530 W. SR 89A VIRTUAL Sedona, AZ OFFICE: 86336
7. What is your insurance? Please include as much information as possible including policy number.
1. Thank you for considering our practice. Once you hit DONE at the end of the questionnaire, your application will be submitted to us electronically and in a HIPAA compliant fashion. If you have not heard
Initial Consultation
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
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
THE GLOBAL HEALTH AND WELLNESS REPORT FINDINGS FROM THE NATIONAL HEALTH AND WELLNESS SURVEY (NHWS)
CATALYSTS DRIVING SUCCESSFUL DECISIONS IN LIFE SCIENCES THE GLOBAL HEALTH AND WELLNESS REPORT FINDINGS FROM THE NATIONAL HEALTH AND WELLNESS SURVEY (NHWS) 2017 Kantar Health INTRODUCTION 2 TABLE OF CONTENTS
CUMULATIVE ILLNESS RATING SCALE (CIRS)
CUMULATIVE ILLNESS RATING SCALE (CIRS) The CIRS used in this protocol is designed to provide an assessment of recurrent or ongoing chronic comorbid conditions, classified by 14 organ systems. Using the
PLEASE COMPLETE ALL SECTIONS OF THIS FORM
PLEASE COMPLETE ALL SECTIONS OF THIS FORM Patient Name: Date of Birth: Referring Doctor? (Name, telephone number and address) Chief Complaint: Why have you come here? How did it start? What are the symptoms?
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?
Family Naturopathic Clinic
Mark Orbay, B.Sc., N.D. Doctor of Naturopathic Medicine 265 Carling Avenue, Suite 610 Tel: (613) 230-6100 Fax: (613) 230-0070 Name: Phone (Home) Address: (Office) Date of Birth: / / Age: (Month) (Day)
Pre-Admission Testing Questionnaire
Pre-Admission Testing Questionnaire Approximately 2 weeks prior to your surgery date you will receive a telephone call from our Pre-Admission Testing department. During this conversation, a Registered
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
Patient s name Patient s phone numbers Emergency contact name Emergency contact phone number Relationship to patient
Advocate Condell Wound Healing Center 801 South Milwaukee Ave, West Tower Libertyville, IL 60048 847-990-5670 Patient s name Patient s phone numbers Emergency contact name Emergency contact phone number
MedStar Medical Group at Forest Hill 1517 Rock Spring Road, Suite C Forest Hill, Maryland Phone (410) Fax (410)
MedStar Medical Group at Forest Hill 1517 Rock Spring Road, Suite C Forest Hill, Maryland 21050 Phone (410) 838-6358 Fax (410) 838-6750 Name Last First MI Preferred Address Street Number Road Apt Number
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
MEDICAL HISTORY FORM FOR FOLLOW-UP
MEDICAL HISTORY FORM FOR FOLLOW-UP ID NUMBER: 0a) Form Date... / / 0b) Staff Code... Instructions: Whenever numerical responses are required, enter the number so that the last digit appears in the rightmost
Pharmacotherapy Handbook
Pharmacotherapy Handbook Eighth Edition Barbara G. Wells, PharmD, HP, FCCP, BCPP Dean and Professor Executive Director, Research Institute of Pharmaceutical Sciences School of Pharmacy, The University
Maineville Family Physician. History and Review of Systems. Name: DOB
Maineville Family Physician History and Review of Systems Name: DOB History of Medical Problems: Please circle the conditions which you have been diagnosed with by a physician and the year or age you were
Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:
Date: / / Patient s Name: Address: Preferred Home: ( ) - Work: ( ) - Cell: ( ) - Text Message Reminders : Yes No Social Security #: Date of Birth: - - / / For ADULT Patients : Employer: Occupation: Spouse
DONE! You can now close the browser.
Visit My Doctor Online at kp.org/mydoctor. Prepare for your visit This form will help you prepare for your upcoming visit with your doctor. You can complete it on your computer (Mac or PC) and e-mail it
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
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:
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service.
Vanguard Rheumatology Partners REGISTRATION FORM (Please Print)
REGISTRATION FORM (Please Print) Today s Date: Primary care doctor: Referring doctor: PATIENT INFORMATION Patient s last name: First: Middle: Sex Age: Marital status: Single Married M F Part Sep Div Widow
Name (First Name and Last Initial ONLY) Date. Occupation. Education. Date of Birth Age Gender. How did you hear about AHE NYC World Student Clinic?
Name (First Name and Last Initial ONLY) Date Occupation Education Date of Birth Age Gender How did you hear about AHE NYC World Student Clinic? Family History Age If passed, cause of death Father Mother
New Patient Medical Questionnaire DATE:
New Patient Medical Questionnaire DATE: Patient Name: DOB: AGE: Other Physicians: Who can we thank for referring you to our practice? Pharmacy Name & Location:` Phone # CHIEF COMPLAINT What problems are
Patient Name: Date of Birth: Date of Visit (Today s Date): Date of Injury (if applicable): Occupation: Right or Left Handed: Referring Provider:
New Patient History & Intake Form Patient Information Patient Name: Date of Birth: Date of Visit (Today s Date): Date of Injury (if applicable): Occupation: Right or Left Handed: Referring Provider: Preferred
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy This form must be scanned into the medical record. Do not remove from clinic. UWMC Women s Health Care Center & SCCA Women s Cancer Center
Adult Health History for NEW Patients
Adult Health History for NEW Patients Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient there is
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
Barbara G. Wells, PharmD, FASHP, FCCP, BCPP Dean and Professor School of Pharmacy, The University of Mississippi Oxford, Mississippi
Barbara G. Wells, PharmD, FASHP, FCCP, BCPP Dean and Professor School of Pharmacy, The University of Mississippi Oxford, Mississippi Joseph T. DiPiro, PharmD, FCCP Panoz Professor of Pharmacy, College
Past Medical History: Medical problems pertaining only to you:
Instructions: Place an X in boxes that apply to you. Make no marks in boxes that do not apply to you. Complete all sections Past : Medical problems pertaining only to you: Cardiac / Heart I have no history
Female New Patient Questionnaire
Patient Demographics First Name: Middle: Last Name: Home Phone: Cell Phone: Email: Address: SSN: City: State: Zip: Age: Date of Birth: Referred by: OBGYN: Occupation: Primary Care Physician: Marital Status:
University Gynecologic Oncology Associates
University Gynecologic Oncology Associates Medical History Form Date: Name: Date of Birth: / / GYNE HISTORY Age of first period? If you no longer have periods, at what age did they stop? Are you pregnant
Eligibility. Information about you. Information about your agent Only complete this section if you have an agent
Visitors to Canada Detailed medical questionnaire Underwritten by CUMIS General Insurance Company, a member of The Co-operators group of companies. How to complete this form: Complete one form for each
LIST ALL CURRENT MEDICATIONS BELOW INCLUDING INJECTIONS/INFUSION MEDICINES MEDS) Name of Medication Dose How often taken
Please take a moment to fill out the following forms front and back: Pharmacy Information: (Include the Name, Address and Phone Number of the Pharmacy) Preferred Local: Preferred Mail Order/Specialty:
o Kidney Cancer o Liver Cancer o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine o Neurological
Adult New Patient Registration PATIENT DOB: / / MONTH DAY YEAR PATIENT NAME: LAST FIRST MI o Abnormal Heartbeat Patient Medical History: Please mark all that apply o Chronic Headaches o Hepatitis C o Neuropathy
NOTICE TO OUR PATIENTS
SMG Chestnut Street, SMG Elm Street, SMG Mancos Valley, Southwest Walk-In Care, Southwest School-Based Health Center, SMG Market Street, SMG Orthopedics, SMG Pulmonary and Sleep Medicine, SMG General Surgery,
PATIENT MEDICAL HISTORY INTAKE FORM
Northgate Professional Center 1985 Main Street, Suite 209 Springfield, Massachusetts 01103 Tel; 413-455-1081 Fax; 413-391-7489 www.marimedconsults.com PATIENT MEDICAL HISTORY INTAKE FORM Patient Information:
Patient Health History
Patient Health History This information is very important in your care. Please complete as carefully and accurately as possible. Name: Date: Height: inches Weight: lbs Age: Symptoms: 1. Type of symptoms
CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:
JOSE G. VELIZ MD, INC. Diplomate of the American Board of Interventional Pain Management Diplomate of the American Board of Anesthesiology Diplomate of the American Board of Pain Medicine Fellow of Interventional
Supplementary materials for:
Supplementary materials for: Cecil E, Bottle A, Sharland M, Saxena S. Impact of UK primary care policy reforms on short-stay unplanned hospital admissions for children with primary care-sensitive conditions.
List of Qualifying Conditions
List of Qualifying Conditions Cancer Conditions 1) Adrenal cancer 2) Bladder cancer 3) Bone cancer all forms 4) Brain cancer 5) Breast cancer 6) Cervical cancer 7) Colon cancer 8) Colorectal cancer 9)
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
Preventive Care Coverage
Preventive Care Coverage Benefits designed to protect your health BridgeSpanHealth.com Review Coverage» To find out if you re eligible for preventive coverage, call the Member Services number on the back
January Intravenous Nurse Day ALL MONTH LONG SUN MON TUE WED THU FRI SAT. Blood Donor Month. Glaucoma Awareness Month
January 1 2 3 4 5 6 Blood Donor Month 7 8 9 10 11 12 13 Glaucoma Awareness Month Volunteer Blood Donor Month Cervical Health Awareness Month 14 15 16 17 18 19 20 Thyroid Awareness Month Birth Defects Prevention
MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History
MEDICAL INFORMATION TODAY S DATE: SOCIAL SECURITY NUMBER: PATIENT NAME: BIRTHDAY: HEIGHT: WEIGHT: AGE: WHO REFERRED YOU? RACE: PRIMARY CARE PHYSICIAN: SEX: DOCTOR S ADDRESS: SECTION 1: Pharmacy Information
Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form
Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI 48103 P (734) 547-3990 F (734) 547-3890 New Patient Intake Form Personal Information Name Age Sex Female Male Gender Identify
Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
Patient Name (First, Middle, Last) Height Weight Date of Birth Social Security # Gender Male Female Ethnicity Race Language Address City State Zip Home Phone Cell Phone Work Phone Other Phone Email Occupation
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
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
FAMILY MEDICINE New Patient Medical History Form
FAMILY MEDICINE New Patient Medical History Form Personal History : Name: Date of Birth / / (mm/dd/yyyy) Age Occupation Birthplace (City&Country) Marital Status (check one): Single Married Divorced Separated
HEALTH MATTERS, INC. SUMMARY OF PROJECTS AND KEY ACCOMPLISHMENTS TO 2016
Selected 2016 Highlights Epidemiologic research on chronic kidney disease and fistula patency, solid and hematologic malignancies Health economics and outcomes research on beta3-agonist treatment for overactive
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
intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:
intake form Page 1`of 5 About You : Name: Sex: Male Female Address: City: State/Province: Country: Zip/Postal Code: Home Phone Number: Mobile Phone Number: Email Address: Birthday: Marital Status: Married
BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY
BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY Thank you for choosing Back To Basics Health & Nutrition to assist you with your natural health care. The ability to draw effective conclusions
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Detailed medical questionnaire Underwritten by Co-operators Life Insurance Company.
canadian expatriates visitors to canada inpatriates to canada Detailed medical questionnaire Underwritten by Co-operators Life Insurance Company. How to complete this form: Complete one form for each person
Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency 1 2 3 4 5 6 7 8 9 10 11 12 13
TOUCHMATTERS MANUAL THERAPY Health History Form NAME: DATE: ADDRESS: (street and number) (city) (postal code) TELEPHONE: (home) (work) (cell)
TOUCHMATTERS MANUAL THERAPY Health History Form The information that you are providing on this form will give me the necessary starting point to help you with your primary complaint. Please be as thorough
Patient Medical History
#3 1810, 8 th Street East, Saskatoon SK S7H0T6 Phone (306) 373-5209 Fax (306) 373 5207 Michelle Kormos, Osteopathy (current study) Patient Medical History Please complete the entire medical history and
Adult Health History for NEW Patients
Adult Health History for NEW Patients Name Date Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are a current patient
ITG Diet Health Status Intake Form
Health Status Intake Form Date: Last Name: First Name: D.O.B: Address: City: ST: ZIP Phone: Cell: Email: Age: HT: WT: BMI: Fat %: Occupation: Sex: M F Marital Status: M S D W How did you hear about the
Morris Medical Center, P.A.
Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~