PATIENT REGISTRATION INFORMATION

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PATIENT REGISTRATION INFORMATION Patient Name (Last, First, Middle): Social Security #: - - Age: Date of Birth: / / Sex: Male Female Language: Marital Status: Race: Ethnicity: Hispanic or Latino Not

1 PATIENT REGISTRATION INFORMATION Patient Name (Last, First, Middle): Social Security #: - - Age: Date of Birth: / / Sex: Male Female Language: Marital Status: Race: Ethnicity: Hispanic or Latino Not Hispanic or Latino Address: Telephone #: Cell Phone #: Address: Employer: Occupation: Employer Address: Employer Telephone #: Extension: Primary Care Physician: Telephone #: Referring Physician: Telephone #: EMERGENCY CONTACT Name: Relationship to Patient: Telephone #: Employer Telephone #: Page 1

2 GUARANTOR INFORMATION Name: Relationship to Patient: Social Security #: - - Age: Date of Birth: / / Sex: Male Female Address: Telephone #: Cell Phone #: Employer: Employer Telephone #: PRIMARY INSURANCE Insurance Name: Insurance Telephone #: ID #: Group #: Claims Mailing Address: Subscriber s Name: Relationship to Patient: Self Spouse Child Subscriber s Employer: Subscriber s Address: Subscriber s Social Security #: - - Subscriber s Date of Birth: / / SECONDARY INSURANCE Insurance Name: Insurance Telephone #: ID #: Group #: Claims Mailing Address: Subscriber s Name: Relationship to Patient: Self Spouse Child Subscriber s Employer: Subscriber s Address: Subscriber s Social Security #: - - Subscriber s Date of Birth: / / Page 2

3 MEDICAL HISTORY If Over the Age of 50, Have You Had a Colonoscopy? No Yes If Yes, When? FOR MALES ONLY: Have You Had a Prostate Exam? No Yes If Yes, When? FOR FEMALES ONLY: Have You Had a Mammogram? No Yes If Yes, When? Have You Had a Pap/Pelvic Exam? No Yes If Yes, When? Is It Possible You are Currently Pregnant? No Yes Last Menstrual Period: / / Current Contraceptive Method: # of Pregnancies: # of Live Births: 1 st Pregnancy Age: Weight Gain: 3 rd Pregnancy Age: Weight Gain: 2 nd Pregnancy Age: Weight Gain: 4 th Pregnancy Age: Weight Gain: Page 3

4 Illness/Diagnosis (please check all that apply): MEDICAL HISTORY CONTINUED Diabetes requires insulin Diabetes requires no insulin HIV Exposure/AIDS Thyroid Disease Insulin Resistance Irregular Menstrual Periods Morbid Obesity 5+ Years Polycystic Ovarian Syndrome Weight Gain Asthma Blood Clots-DVT Blood Clots to Lungs-PE Emphysema (COPD) Lung Disease/COPD Pneumonia Shortness of Breath w/ Activity Shortness of Breath at Rest Sleep Apnea Sleep Apnea CPAP Machine Sleeping Problems Snoring Tuberculosis Chest Pain w/ Activity (Angina) Chest Pain at Rest (Angina) Chronic Leg Sores Congestive Heart Failure Heart Attack Heart Disease Heart Palpitations High Blood Pressure High Cholesterol Irregular Heart Rate or Rhythm Leg Discoloration Leg Swelling/Edema Swelling of Ankles/Feet Aspiration/Choking Chronic Abdominal Pain Heartburn or Reflux Hiatal Hernia Nausea Nausea-Vomiting Stomach Ulcers Trouble Swallowing Ulcers/Gastritis Arthritis Chronic Back Pain Chronic Fatigue Chronic Joint Pain Chronic Headache Seizure Disorder Stroke Anxiety Bipolar Disorder Depression Low Self-Esteem Panic Attacks Drowsy Days Exercise Limitations-mild Exercise Limitationsmoderate Exercise Limitations-severe Fevers/Chills/Sweats Frequent Colds Gallbladder Attacks Gallbladder Disease Iron Deficient Anemia Skin Rash Urinary Incontinence Vitamin D Deficiency Cancer Please list any other illness/diagnosis: Page 4

5 MEDICAL HISTORY CONTINUED Physical Limitations/Disabilities (please check all that apply): Airline Travel Lifting Objects from Floor Unusual Fatigue Caring for Personal Needs Playing with Children Use of Public Seating Climbing Stairs Tying Shoes When Exposed to the Following, Do You Have Symptoms Like Red Itchy Eyes, General Itching, Shortness of Breath, Wheezing, Fast Heartbeat, Feeling Faint, Nausea or Vomiting Aspirin? Yes No Iodine? Yes No Latex? Yes No Rubber (Balloons, Band-Aids, Spandex, Tape)? Yes No Please List Any Previous Cardiac Procedures or Testing and Cardiologist Name: FAMILY MEDICAL HISTORY Illness/Diagnosis (please check all that apply): No information Bowel/Colon Disease Stroke Diabetes Hepatitis Arthritis Morbid Obesity Kidney Disease Depression/Anxiety Heart Disease Liver Disease Other: High Blood Pressure Bleeding Disorder Other: Heart Attack Cancer Other: Asthma Clotting Disorder Other: Emphysema/COPD Breast Disease Other: SURGICAL HISTORY Surgical Procedures (please check all that apply): Back/Neck Surgery Roux-N-Y Gastric Bypass Surgery to the Small Bowel Caesarean Section Sleeve Gastrectomy Surgery to the Stomach Dilation & Curettage (D&C) Surgery to the Chest or Lung Tonsillectomy Gallbladder Surgery to the Esophagus Other: Gastric Banding Surgery to the Heart Other: Hysterectomy Surgery to the Large Bowel Other: Surgical Complications (please check all that apply): Anesthesia Problems Blood Transfusion Other: Bleeding Infections Other: Please List Other Significant Conditions or Hospitalizations: Page 5

6 NUTRITIONAL HISTORY # of Meals Per Day: Do You Eat Between Meals? Yes No # of Glasses of Water Per Day: Food Preferences (please check all that apply): Cakes/Pies Cookies Pizza Candy Dairy Products Seafood Chips/Snacks Fast Food Steak/Red Meat Chocolate Fried Food Vegetables SOCIAL HISTORY Do You Use Tobacco? No Yes If Yes, What Type? Chew Cigarettes Cigar Pipes # Per Day: # of Years: If You Quit, When? Do You Drink Sodas? No Yes If Yes, What Type? Diet Regular # Per Day: Do You Drink Alcoholic Beverages? No Yes If Yes, How Many Times Per Week? Do You Drink Coffee/Caffeine? No Yes If Yes, How Many Cups Per Day? Have You Ever Used Marijuana or Other Illicit Drugs? Do You Tolerate Physical Exercise? Do You Have Trouble Sleeping? No Yes No Yes No Yes Page 6

7 MEDICATIONS Please list any medication allergies: Preferred Pharmacy: Location/Address: CURRENT MEDICATIONS Medication Name Strength Frequency Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Prescription Over-the-Counter Page 7

8 WEIGHT LOSS HISTORY Diet Year(s) Weight Lost # of Months on Program Acupuncture Behavior Modification Exercise Fen-Phen Hypnosis Injections Jenny Craig Meridia Nutritionist/Dietitian Psychiatrist/Therapy Opti-Fast Overeaters Anonymous Redux Richard Simmons Weight Watchers Xenical Physician-Directed Plan(s) List: List: Self-Monitored Diet(s) List: List: Page 8

9 BAILEY MEDICAL CENTER OWASSO, OKLAHOMA EPWORTH SLEEPINESS SCALE (01/14) Review (01/17) Patient Name: Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations? Rate each description according to your normal way of life in recent times. Even if you have not been in some of these situations recently, try to determine how sleepy you would have been. Use the following scale to choose the best number for each situation: 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Situation Chance of Dozing Sitting and reading Watching TV Sitting inactive in a public place (e.g., a theater or meeting) Sitting as a passenger in a car for an hour without a break Lying down to rest in the afternoon when your schedule permits Sitting and talking to someone Sitting quietly after lunch without alcohol Sitting in a car while stopped for a few minutes in traffi c

10 Obstructive Sleep Apnea Assessment Patient Name: DOB: If you need help answering any of these questions please ask the Medical Assistant for assistance once they have taken you to the exam room. If yes, when and where: Current use of CPAP? If you have been previously diagnosed with Obstructive Sleep Apnea and instructed to use a CPAP do you use it as prescribed? If no,why? History of Abnormal Sleep Symptoms: Do you have a personal history of any of the following? 1. (abnormal movement, behavior, emotions, or dreams while sleeping) Excessive Daytime Sleepiness 5. Insomnia? (Inability to sleep) 6. Has anyone ever told you that you stopped breathing during sleep? 7. Have you experienced gasping or choking while sleeping? 8. Do you frequently arouse during sleep? 9. If you answered yes to any abnormal sleep symptoms, how long have you been experiencing them?

11 Do you have a personal medical history of any of the following? 10. High Blood Pressure 11. Use of three or more medications to treat High Blood Pressure 12. Any head or facial or upper airway soft tissue abnormality euromuscular disease 15. Stroke in the past 30 days? 16. Mini strokes (Transient ischemic attacks (TIA)) 17. Coronary artery disease (CAD) 18. No Fast heart rate (tachycardia) 19. Slow heart rate (bradycardia) 20. COPD 21. Congestive Heart Failure (CHF) 22. Physical inability to safely apply home sleep testing equipment 23. Periodic Limb Movement Disorder Narcolepsy 26. Idiopathic Hypersomnia 27. Nocturnal Seizures 28. Use of home oxygen 29. Use of prescription narcotic pain medication 30. Obesity hypoventilation syndrome *** To be filled out by clinic staff only*** BMI Neck circumference inches

PATIENT REGISTRATION INFORMATION

PATIENT REGISTRATION INFORMATION Patient Name (Last, First, Middle): Social Security #: - - Age: Date of Birth: / / Sex: Male Female Language: Marital Status: Race: Ethnicity: Hispanic or Latino Not Hispanic