General Information. ~ 1 ~ Harmony Integrative Medicine Clinic, PLLC. Name: Date of Birth: Age: Gender: Male Female
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1 General Information Name: of Birth: Age: Gender: Male Female Primary Address: Street # Apt# City State Zip Home Number Cell Number Job Title Nature of Business Emergency contact Name phone # Cell # Primary Care Physician: Name Office # Office Fax # Primary Pharmacy: Name Phone # Fax# Compounding Pharmacy: Name Phone # Fax# Insurance Carrier: Mailing: Policy Number# Group # Insurance Provider Phone # ~ 1 ~ Harmony Integrative Medicine Clinic, PLLC
2 Medical Questionnaire Medical History Current Diseases/Diagnosis/Conditions check all that apply Cardiovascular Heart attack Other heart disease Stroke/TIA Elevated cholesterol Arrhythmia (irregular heartbeat) Hypertension Rheumatic fever Mitral valve prolapsed CHF CAD Angina Other: Musculoskeletal Osteoporosis Fibromyalgia Osteoarthritis Edema Gout Chronic pain Sjogren s disease Other: Neurological Anxiety Depression Mood swings Seizures Memory loss Tremors Vertigo ADD/ADHA Headaches/Migraines Dementia Parkinson s disease Other: Metabolic/Endocrine Type 2 Diabetes Anorexia Hypothyroidism Hyperthyroidism Metabolic syndrome PCOS Binge eating Bulimia Weight gain Weight loss (unexplained) Caffeine dependency Hypoglycemia Type 1 Diabetes PMS Other: Cancer Lung cancer Breast cancer Colon Cancer Ovarian cancer Prostate cancer Skin cancer Cervical cancer Brain cancer Lymphoma Other: Skin Acne Cellulite Eczema Hair loss Body odor Psoriasis Moles with changing color Excessive sweating Fungal infection Other: Respiratory Chronic cough Sleep apnea COPD Shortness of breath Bronchitis Chronic sinus infection Asthma Allergies Snoring Other: Autoimmune/inflammatory Chronic fatigue syndrome Rheumatoid arthritis Herpes Food allergies Latex allergies Frequent/Chronic infections Autoimmune disorder Muscular Sclerosis Muscular Dystrophy Other: Lupus Urinary/Reproductive Kidney disease Urinary incontinence Poor libido Enlarged prostate Irregular periods Impotence Yeast infections STD Infertility Endometriosis Other: Gastrointestinal IBS Celiac disease Hemorrhoids Inflammatory bowels Peptic ulcer Crohn's disease Liver disease Colitis Excess gas GERD Other: ~ 2 ~ Harmony Integrative Medicine Clinic, PLLC
3 Allergies Medication/Supplement/Food Reaction Current Medication_ Medication Dose Frequency Start date Reason for Use Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathy) Supplication & Brand Dose Frequency Start Reason for Use Hospitalization Reason for hospitalization Specialists Name Phone number Reason seen next appointment ~ 3 ~ Harmony Integrative Medicine Clinic, PLLC
4 Medical History continued Preventative Tests Testing Results Physical Exam Bone Density Mammogram Pap Smear EKG Chest X-Ray Colonoscopy Upper GI Scope Cardiac Stress Test Echocardiogram Ultrasound: (Type) MRI: (area) Ct Scan: (area) Surgical History Type of Surgery ~ 4 ~ Harmony Integrative Medicine Clinic, PLLC
5 Family History Check all that apply Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandmother Other Age (if still Alive) Age at Death (if deceased) Colon Caner Breast or Ovarian Cancer Heart Disease Hypertension Hypercholesterolemia Obesity Diabetes Stroke Inflammatory Arthritis Inflammatory Bowel Disease Auto Immune Disease Irritable Bowel Syndrome Celiac Disease Asthma Eczema/Psoriasis Dementia ALS or other motor neuron disease Genetic Disorder Substance Abuse Psychiatric Disorder ADHD Autism Parkinson's Food Allergies Environmental Allergies Cancer (other) Other ` Social History Race African American Asian European Native American Middle Eastern Hispanic Caucasian other Roles/Relationships Marital status: Single Married Divorced Long term relationship Widow Number of children? Number living in household fulltime? Smoking History Currently Smoking? yes no How Many Years? Packs per day: Attempts to quit: Previous Smoking: How many years? Packs per Days? Second hand smoke Exposure? Alcohol Intake How many drinks currently per week? 1 drink= 5 oz wine, 12oz beer, 1.5oz spirits none >10 If none skip to Other Substances Previous alcohol intake? yes ( mild moderate high) None Other Substances Caffeine intake: Yes No Coffee cups/day: >4, Tea cups/day: >4 Caffeinated Sodas or Diet sodas intake: yes no 12oz can/bottle >4 Have you ever used IV or inhaled recreational drugs? yes no if yes when? ~ 5 ~ Harmony Integrative Medicine Clinic, PLLC
6 Symptom Review Please check all that apply at the present time or in the past 6 months General Cold Hands and Feet Cold/heat intolerance Low Body Temperature Low Blood Pressure Daytime Sleepiness Difficulty Falling Asleep Early Waking Fatigue Fever Flushing Hear Intolerance Night Waking Nightmares Other: Head, Eyes & Ears Conjunctivitis Distorted Sense of Smell Distorted taste Ear Fullness Ear Pain Ringing in the Ear Eye Crusting Hearing Loss Hearing Problems Headache Vision problems Musculoskeletal Muscle spasm Muscle cramps Chest tightness Join pain Joint swelling Neck pain Numbness Muscle weakness Neurologic/Psych Anxiety Depression Mood swings PMS Seizures Memory loss Dizziness Numbness/tingling Tremors Vertigo Poor concentration Eating Habits Binge eating Poor appetite Caffeine dependency Sweet cravings Salt cravings Frequent dieting Weight gain Weight loss Digestion Bloating Abdominal pain/cramping Gas/ Belching Blood in stool Acid reflux Hemorrhoids Nausea Vomiting Difficulty swallowing Constipation Diarrhea Food intolerance Skin Acne Dark circles under eyes Eczema Hives Rash Hair loss Itching Psoriasis Dry eyes Dry skin Oily skin Sensitive skin Bumps on back of arms fungal infections Respiratory Cough Hoarseness Sore throat Shortness of breath Nasal congestion Frequent sinus infection Nose bleeds Allergies Snoring Cardiovascular Chest pain rapid heart rate Irregular pulse Palpitations Varicose veins Swelling to limbs Urinary/Reproductive Urinary urgency Leaking/incontinence Painful urination Vaginal itching/drainage Irregular periods Poor libido Breast lumps Genital pain Ejaculation problems Discharge Ovarian cyst Pain with intercourse Lump on testicle ~ 6 ~ Harmony Integrative Medicine Clinic, PLLC
7 Other significant information: The above information is true to the best of my knowledge. I understand that I am financially responsible for all professional services, regardless of insurance coverage. Patient signature Patient (print name) Staff signature ~ 7 ~ Harmony Integrative Medicine Clinic, PLLC
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
What do you believe is causing your most important health concern?
Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to
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
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
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
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
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:
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
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1 NAME: DATE OF BIRTH PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS: PAST MEDICAL HISTORY (YOUR MEDICAL HISTORY) :
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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
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.
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL NAME: BIRTH DATE: AGE: SEX: M F OCCUPATION: RACE: WHO REFERRED YOU TO OUR OFFICE? _ WHAT IS YOUR MAIN COMPLAINT? HOW LONG HAS THIS BEEN A PROBLEM? IS
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
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD Phone: 706-850-8322 Fax: 706-850-8322 PATIENT HISTORY FORM Date of first appointment: / / Time of appointment: Birthdate: Name LAST FIRST MIDDLE INITIAL
2. Have your symptoms affected your ability to carry out your daily activities? YES NO
QUESTIONNAIRE Page 1 of 5 Date: Referring MD (Name, Address, Phone Number): Primary Care Physician (Name and Address, Phone Number): Reason for visit: 1. How long have you had symptoms? Describe your symptoms?
DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address: