LenaC.Schaffer,M.D. 700FrontStreet,#102 Louisvile,Colorado80027 Office: Fax:
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1 LenaC.Schaffer,M.D. 700FrontStreet,#102 Louisvile,Colorado80027 Office: Fax:
2 LenaC.Schaffer,M.D. 700FrontStreet,#102 Louisvile,Colorado80027 Office: Fax:
3 Vascular Ultrasound test) Prostate Exam Immunizations Immunization Date Immunization Date Immunization Date Tetanus/Td Pneumonia Varicella Influenza (FLU) Hepatitis Family History Check boxes if a blood relative has suffered any of the following indicate which relative(s), and give details below 1. Anemia 2. Alcoholism 3. Alzheimer s 4. Arthritis 5. Asthma 6. Bleeds easily 7. Cancer 8. Diabetes (type) 9. Epilepsy 10. Glaucoma 11. Hay fever 12. Heart disease 13. Hepatitis 14. Hypertension 15. Lipid 16. Mental illness disorder Stroke 19. Thyroid dx 20. Osteoporosis Has your mother had a hip fracture after age 50?: Yes No Family History Details (indicate the number above, which relative(s) and explain): Medical History Enter X and indicate age or dates for all questions which have ever applied to you. C for current ongoing problems, providing dates and details Decreased Hearing Abdominal pain - chronic Ringing in ear Gall bladder trouble Ear infections frequent Jaundice / Hepatitis Dizzy spells Have bowel movement every day(s) Fainting spells Frequent: Constipation Diarrhea Failing vision Diverticulosis Eye pain Crohn s / Colitis Double or blurred vision Bloody or tarry stools Nose bleeds recurrent Hemorrhoids Sinus trouble Hernia; type- Sore throats frequent Urination Overactive bladder Hoarseness prolonged Overnight > than twice Dental problems: More than 8 times/24 hrs. Floss teeth times per week Urgency to urinate Hay fever / Allergies Decrease in urinary force/flow Pneumonia / Pleurisy Painful urination Bronchitis / Chronic cough Urine leakage with: Exercise/ /Straining/Cough Shortness of breath: Exertional Lying Blood in urine flat Asthma / Wheezing Kidney stones Chest pain Urine infections frequent High blood pressure Sexually transmitted diseases: Heart murmur Recent weight- Gain Loss: lbs. Rapid heart beat Desired weight: lbs. 2007, Gregory W. Petersburg, D.O., All rights reserved 2.16
4 Swollen ankles Irregular pulse Palpitations Leg pain when walking Varicose Veins / Phlebitis Cold numb feet Anemia Bruise easily Blood transfusions Cancer; type(s)- Chronic fatigue Diabetes Loss of appetite recent Seizures Difficulty swallowing Stroke Heartburn Tremor / hands shaking Peptic ulcer Numbness / tingling sensations Persistent nausea / Vomiting Headaches frequent Bone fracture / joint injury Arthritis; type/location: Fractures after age 50? Yes No Back pain recurrent Foot pain Coffee Tea cups/day Osteoporosis Alcohol: Never Rarely Weekly Daily Gout Beer Wine Liquor; # drinks: Rashes Gotten drunk in the past month? Yes No Hives Felt the need to stop drinking? Yes No Psoriasis Smoking:# cigars/cigarettes/day; yrs Eczema Year quit smoking: Sleeping difficulty Recreational drugs: Concentration difficulty Acupuncture Tattoos Depression Abuse: Physical Sexual Other Nervousness Hair loss: Progressive Recent Agitation Do you have a lack of energy? Memory loss Do you have less strength/endurance? Moodiness Have you lost height? inches Suicidal thoughts Decreased enjoyment of life? Phobias Are you sad and/or grumpy? Mental illness Recent deterioration in ability to play sports? Feelings of worthlessness Are you falling asleep after dinner? Rheumatic Fever Recent deterioration in work performance? Scarlet Fever Do you have a decrease in libido? Chicken Pox Satisfied with orgasm frequency? Yes No Polio Are you sexually active? Past Current Mumps Opposite sex German measles Same sex Tuberculosis Single partner Herpes Multiple partners Aids / HIV # of sex partners in past year: Thyroid disease 2007, Gregory W. Petersburg, D.O., All rights reserved 2.16
5 Females (complete the following section) Age when you started menstrual periods: Pregnancies: If menopausal, date of your last period: Abortions: Date of the 1 st day of your last period: Miscarriages: Periods start every days; # of days of flow: Live births: Age at 1 st delivery: Periods: Regular Irregular Pain/Cramps Did you ever breast feed? Yes No Pain / Bleeding during or after sex: Yes No Birth control method: Females- check only those symptoms you currently experience: Mental fogginess Increase of breast size Forgetfulness Water retention Depression Impatient, snappy behavior Minor anxiety Pelvic cramps Mood change Nausea Females (continued) Check only those symptoms you currently experience: Difficulty falling asleep Flabbiness and muscular weakness Hot flashes Loss of hair Night sweats Lack of energy and stamina Temperature swings Loss of coordination and balance Day-long fatigue Decreased sex drive Decreased sense of sexuality Decreased hair - armpit, pubic, body Lessened self-image Harder to reach climax Dry eyes, skin and vagina Sagging breasts and loss of fullness Pain with sexual activity How do/did you feel during different days of the month of your cycle? How do/did you feel a few days before and during the period? How do/did you feel from the day of ovulation to the onset of heavy flow? Did you develop signs of deficiency after starting birth control pills? Did you feel miserable, gain weight or did breast size increase after starting birth control pills? Did you feel better after starting birth control pills? Males (complete the following two sections) Symptoms at this time None Mild Moderate Severe Extreme Decline in your feeling of general well-being Joint pain and muscular ache Excessive sweating Sleep problems Increased need for sleep, often feeling tired Irritability Nervousness Anxiety Physical exhaustion / lack vitality Decrease in muscular strength Depressive mood Feeling that you have passed your peak Feeling burnt out, having hit rock bottom Decease in beard growth Decrease in ability / frequency to perform sexually 2007, Gregory W. Petersburg, D.O., All rights reserved 2.16
6 Decrease in the number of morning erections Decrease in sexual desire / libido Over the past month how often have you: Had sensation of not emptying bladder completely after urinating? Had to urinate again less than 2 hrs. after urinating? Stopped and started urinating several times? Found it difficult to postpone urination? Had a weak urinary stream? Had to push or strain to begin urinating? Typically up to urinate from bedtime to getting up? Not at All < 1 time in 5 < Half the time Half the time > Half the time Almost Always 2007, Gregory W. Petersburg, D.O., All rights reserved 2.16
7 Nutrition List any diets you have been on during the past 12 months, along with the reason(s) for following it, the benefits or problems you experienced with it, and the reason(s) for stopping any diet: Exercises Current Sources of Stress Miscellaneous Additional information you would like to share, or to elaborate on previous questions Patient Signature: Date: 2007, Gregory W. Petersburg, D.O., All rights reserved 2.16
8 LenaC.Schaffer,M.D. 700FrontStreet,#102 Louisvile,Colorado80027 Office: Fax:
9 shoulders When I scratch my skin, a white line remains for a minute or more I have unexplained and frequent headaches I am frequently cold I often become hungry, confused, shaky or somewhat paralyzed under stress I have lost weight without reason while feeling very tired and listless I have feelings of hopelessness or despair I have decreased tolerance. People irritate me more The lymph nodes (glands) in my neck are frequently swollen I often have to force myself in order to keep going. Everything seems like a chore I am easily fatigued I have difficulty getting up in the morning (don t really wake up until about 10 AM) I suddenly run out of energy I usually feel much better and fully awake after the noon meal I often have an afternoon low between 3 5 PM I get low energy, moody or foggy if I do not eat regularly I usually feel my best after 6 PM I am often tired at 9-10 PM, but resist going to bed I like to sleep late in the morning My best, most refreshing sleep often comes between 7-9 AM I often do my best work late at night (early in the morning) If I don t go to bed by 11 PM, I get a second burst of energy around 11 PM, often lasting until 1-2 AM I get coughs/colds that stay around for several weeks I have frequent or recurring bronchitis, pneumonia or other respiratory infections I get asthma, colds and other respiratory involvement two or more times per year I frequently get rashes, dermatitis, or other skin conditions I have rheumatoid arthritis I have allergies to several things in the environment I have multiple chemical sensitivities I have chronic fatigue syndrome I get pain in the muscles of my upper back and lower neck for no apparent reason I get pain in the muscles on the sides of my neck I have insomnia or difficulty sleeping I have Fibromyalgia I suffer from asthma I suffer from hay fever I suffer from nervous breakdowns My allergies are becoming worse (more severe, frequent or diverse) The fat pads on palms of my hands and/or tips of my fingers are often red I have a tenderness near the bottom of my rib cage in my back when pressed I bruise more easily than I used to I need coffee or some other stimulant to get going in the morning I have swelling under my eyes upon rising that goes away after I have been up for 2007, Gregory W. Petersburg, D.O., All rights reserved 2.31
10 a couple of hours I often crave food high in fat and feel better with high fat foods I use high fat foods to drive myself I often use high fat foods and caffeine containing drinks (coffee, colas, chocolate) to drive myself I often crave salt and/or foods high in salt. I like salty foods I feel worse after high potassium foods (e.g. bananas, figs, raw potatoes), esp. if eaten in the morning I crave high protein foods (meats, cheeses) I crave sweet foods (pastries, doughnuts, dried fruits, candies, and desserts) I feel worse if I miss or skip a meal I have constant stress in my life or work My dietary habits tend to be sporadic and unplanned My relationships at work and/or home are unhappy I do not exercise regularly I eat lots of fruit My life contains insufficient enjoyable activities I have little control over how I spend my time I restrict my salt intake I have gum and/or tooth infections or abscesses I have meals at irregular times I feel better almost right away once a stressful situation is resolved Regular meals decrease the severity of my symptoms I often feel better after spending a night out with friends I often feel better if I lie down Other relieving factors: I am chronically fatigued; a tiredness that is not usually relieved by sleep * I sometimes feel weak all over * I have decreased tolerance for cold * I have times of nausea and vomiting for no apparent reason * I have low blood pressure * Women Only (next 2 questions only) I have increasing symptoms of premenstrual syndrome (PMS) such as cramps, bloating, moodiness, irritability, emotional instability, headaches, tiredness, and/or intolerance before my period (only some of these need be present) My periods are heavy but often (almost) stop on the 4 th day, & start up profusely on the 5 th or 6 th day Place a Check Next to any Description that Applies to You (**) Any areas that have become bluish-black color?: ** inside lips/mouth, vagina, around nipples Increased darkening around bony areas, at skin folds, scars and in joint creases? ** Light colored patches on skin where it has lost its usual color? ** Fainting spells? ** Frequent unexplained diarrhea? ** 2007, Gregory W. Petersburg, D.O., All rights reserved 2.31
11 Easily become dehydrated? ** Adapted from: Adrenal Fatigue the 21 st Century Stress Syndrome, by James Wilson N.D. 2007, Gregory W. Petersburg, D.O., All rights reserved 2.31
12 Wellness Profile Patient Name Address Are you currently taking a multi-vitamin? Are you currently taking an Omega fatty acid product? Are you familiar with the importance of probiotics? Would you like to speak with your doctor about a safe and effective cholesterol support? Would you like to discuss the use of antioxidants? Did you know that if you are taking a statin, that CoQ10 is depleted from your body? If you are on a statin, are you taking a CoQ10 product? Do you currently exercise? Are you aware that both men (1 in 4) and women (1 in 2) are at risk for osteoporosis? Are you currently taking anything for bone health? Please list any supplements you are currently taking. What is your long term health goal:
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PATIENT REGISTRATION FORM Address: City: Contact: State: Zip: Home Phone: Email: Work: Cell: Date of Birth: SSN#: Age: Gender: I am: q Married q In a Partnership q Separated q Divorced q Widowed q Single
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
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist
*All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City:
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
Patient Information Form
Patient Information Form Health Card # Version Code Expiry Date (If applicable) (If applicable) Last Name: First Name: Birth date: (Please write the exact name that is on your Health Card) Month / Day
Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification
Long Island Pulmonary and Sleep Medicine Associates, PLLC Louis Saffran, MD FCCP Frank S. Coletta, MD FCCP Karen Mrejen-Shakin, MD FCCP Aviva Kamath, MD FCCP Sepideh Sedgh DO 200 North Village Avenue Suite
Health History. Personal Health History. Institute of Complementary Medicine. FOC Health History - ICM
Reason for office visit today FOC Health History - ICM Health History Whom may we thank for referring you today? Do you have another primary care provider? Date of last physical exam Previous or referring
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
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
Medicare Annual Wellness Visit Patient History
Grace Health Medicare Annual Wellness Visit Patient History Name Date Birthdate Languages Spoken Date of Last Wellness Visit Do you have an advance directive or living will? Yes Don t Know Want Information
New Patient Specialty Intake Form Department of Surgery
This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip:
Date: Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: E-mail: Person to Contact in Case of Emergency: Relationship
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
Adult Health Summary
Adult Health Summary Name: Date: Date of birth Home ph: May I call you at this number? Age Work ph: May I call you at this #? Cell ph: May I call you at this number? E-mail: May I contact you via e-mail?
55 S. Main Street, Driggs, ID (208)
Elements of Health 55 S. Main Street, Driggs, ID 83422 (208) 920-0312 Name: (first) (middle) (last) Date: / / Address: Phone: / street address city zipcode home / cell Date of Birth: / / Age: Gender: M/F
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
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)
MEDICAL QUESTIONNAIRE (female)
MEDICAL QUESTIONNAIRE (female) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501 The appointment comprises of a discussion about this questionnaire and a subsequent medical examination.
Patient First Name Patient Middle Initial Patient Last Name. Primary Care Physician Primary Care Physician Phone Pharmacy Name
NP Hagans Walk-In Clinic * 9135 Piscataway Rd. # 320 Clinton, MD 20735 * (240)-412-5093 (Office) Patient Information Patient First Patient Middle Initial Patient Last Sex Marital Status Date of Birth Social