His Branches Health Services NEW PATIENT HISTORY FORM
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- Henry Stafford
- 5 years ago
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1 Medical Conditions: Please list all major medical conditions, when they first started, and when they resolved, if appropriate, or check None if you have no ongoing conditions: Condition or Diagnosis Date Started Date Resolved Specialists involved in your care: Specialist s Name Specialty Condition Immunizations: Please obtain and/or attach a copy of your immunization record, if possible. Date of most recent Tetanus booster: NPP-HB - Revised / A Community Health Center Operated by His Branches, Inc. Page
2 Medications: Please list all prescriptions and any over the counter medications or herbal supplements you are taking, or check None if you are not taking any medicines or supplements: Name of Medication Dose, e.g. 0 mg How Often, e.g. x/day Primary Pharmacy: Name Address Phone Number Allergies: Medication, Food, or Substance Reaction NPP-HB - Revised / A Community Health Center Operated by His Branches, Inc. Page
3 Hospitalizations and Past Medical Conditions: Please list all serious injuries, hospitalizations or surgeries (except Obstetrical History of pregnancies, see box below), including the approximate date or your age at the time, as best you can remember, or check None if appropriate: Hospitalization, Surgery or Serious Injury Age or Date Pregnancies: Not applicable Date Weeks M or F Type of Delivery Location Complications Total Pregnancies: Term births: Preemies: Miscarriages: Abortions: NPP-HB - Revised / A Community Health Center Operated by His Branches, Inc. Page
4 Family History: Your Relatives Father Mother Brothers Their Names Birth Year Year/Cause of Death Medical Conditions? (Use Numbers listed below*) Sisters Sons Daughters Mother s Mother Mother s Father Father s Mother Father s Father Other * List of Conditions (use numbers in boxes above) Heart Disease (CAD) 7 Colon cancer Stroke (CVA) 8 Breast or Prostate cancer Diabetes (DM) 9 Lung cancer High blood pressure (HTN) 0 Emphysema (COPD) High cholesterol (Chol) Thyroid Arthritis Obesity Other NPP-HB - Revised / A Community Health Center Operated by His Branches, Inc. Page
5 Review of Systems (Symptoms or Conditions you have now or have had in the past): Condition Have now? Had in past? Notes CONSTITUTIONAL (GENERAL) Weight loss Weight gain Fever Fatigue EYES Double vision Spots before eyes Vision changes HEAD / EARS / NOSE / THROAT Headaches Ear aches Ringing in ears Hearing loss Sinus problems Sore throat Mouth sores Dental problems CARDIOVASCULAR (HEART) High Blood Pressure Chest pain Heart Disease / Heart Attack(s) Difficulty breathing Swelling of legs Heart palpitations Heart murmurs Rheumatic fever Stroke RESPIRATORY (LUNG) Wheezing Spitting up blood Shortness of breath Chronic cough Asthma TB or other lung NPP-HB - Revised / A Community Health Center Operated by His Branches, Inc. Page
6 Review of Systems (continued): Condition Have now? Had in past? Notes GASTROINTESTINAL Nausea or vomiting Acid reflux or heartburn Stomach or intestinal problems Peptic ulcer disease Hepatitis, Mono, or liver problems Gall bladder disease Diverticulosis/itis Frequent diarrhea Constipation Bloody stool Colitis Colon Cancer GENITOURINARY Blood in urine Painful urination Urgency Urinary frequency Incomplete emptying Stress incontinence Abnormal periods Painful intercourse Loss of libido (interest in sex) Erectile dysfunction Sexually transmitted diseases Frequent vaginal infections Infection of uterus, tubes, ovaries Abnormal Pap smear Uterine or Ovarian Cancer SKIN / BREAST Pain in breast Nipple discharge Masses Breast Cancer Skin Rash or Ulcers NPP-HB - Revised / A Community Health Center Operated by His Branches, Inc. Page
7 Review of Systems (continued): Condition Have now? Had before? Notes NEUROLOGICAL Frequent severe headaches Dizziness Numbness Trouble walking Epilepsy / Convulsions MUSCULOSKELETAL Muscle weakness or cramps Joint problems Fibromyalgia MENTAL / EMOTIONAL HEALTH Mental or emotional problems Depression Crying frequently Hopelessness Fatigue Lack of motivation Poor concentration No interest in activities Marked decrease in sexual desire Exaggerated sexual desire Anxiety Irritability Panic attacks Insomnia Loss of appetite Increased appetite Suicidal thoughts Struggling with guilt ENDOCRINE (GLANDULAR) Dry skin Abnormal thirst Hot flashes Diabetes Thyroid Disease NPP-HB - Revised / A Community Health Center Operated by His Branches, Inc. Page 7
8 Review of Systems (continued): Condition Have now? Had in past? Notes HEMATOLOGICAL (BLOOD) Frequent bruises Cuts that do not stop Bleeding Enlarged lymph node Anemia (low blood count) Sickle Cell Blood clots or clotting disorder Varicose veins Leukemia or Hodgkin s Disease Other Cancer (what kind?): Nicotine Use: Smoking Status: Never smoked Occasional smoker Everyday smoker Former smoker If you were or are a smoker, what do you smoke? Cigarettes (#/day ) Cigars (#/day ) Pipe (#/day ) Other Sources of Nicotine: Snuff Chewing tobacco E-cigarettes Nicotine gum Other information: NPP-HB - Revised / A Community Health Center Operated by His Branches, Inc. Page 8
9 Social History: HABITS Do you drink alcohol? Y N What? /How much? Quit date? Caffeinated beverages? Y N What? /How much? Quit date? Do you use drugs? Y N What? /How much? Quit date? Do you exercise? Y N How? Days/week? Minutes/day? EDUCATION / EMPLOYMENT How far did you go in school? Elementary High School Some College College Professional School Name of College/Degree: Work (circle one): Full-time Part-time Unemployed Disabled Year last worked Employer: Position: Military Service (circle one): None Army Navy Air Force Marines Coast Guard Merchant Marine Year of draft or enlistment: Year of discharge: PERSONAL INFORMATION Where were you born? Where were you raised? Ethnicity (circle one): Asian African American Caucasian Latino Other Living arrangements (circle one): Apartment Group home -story house -story house Marital status (circle one): Single Married Separated Divorced Widowed Sexual orientation (circle one): Straight Gay/Lesbian Bisexual Transgender Have you ever had an STI/STD? Y N Kind/Date? Are you HIV positive (circle one): Y N Not tested Faith (circle one): Catholic Protestant Evangelical Pentecostal Jewish Other: Place of worship: Do you have any hearing or other communications barriers? Other information: NPP-HB - Revised / A Community Health Center Operated by His Branches, Inc. Page 9
10 For Women Only: MENSTRUAL HISTORY How old were you when you started your first period? Do you have a period every month? Y N Date of your last menstrual period (first day): Interval (number of days from the start of one period to the start of the next): Number of days of flow / bleeding: Do you have any of the following? Cramps Y N Vaginal sores Y N Discharge Y N Bleeding w/intercourse Y N Vaginal odor Y N Painful intercourse Y N Have you ever had a mammogram? Y N When? Have you ever had a pelvic exam? Y N Date of last pap smear Normal / Abnormal Where? Have you ever had an abnormal pap smear? Y N Treatment/Date Do you douche/use feminine hygiene products? Y N How often? CONTRACEPTIVE HISTORY: If Applicable Have you ever used any birth control method to keep you from getting pregnant? Y What methods have you used in the past? (Check all that apply) Withdrawal (pulling out) Injections (Depo shot) Luck Oral (the pill) Vaginal sponge Abstinence Condoms Vasectomy Rhythm (calendar) Diaphragm IUD (type: ) Natural Family Planning Foam, jelly, cream Tubal ligation Other What method are you currently using? How long have you been using this method? What method do you want to use now? Age at your first sexual intercourse? Total # of sexual partners: Are you trying to get pregnant? Y N For how long? N NPP-HB - Revised / A Community Health Center Operated by His Branches, Inc. Page 0
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ALLERGIES. If yes, please list the food and non-medication (i.e. latex) allergies and type of reaction you had: MEDICATIONS
Name: Birthdate: What is your main health concern today? Do you currently use tobacco? YES NO Have in the past? YES NO Year Quit If yes, what kind of tobacco?_number of years: Amount of tobacco per day:
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
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
New Patient Medical History Form
New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
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.
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
IN CASE OF AN EMERGENCY NOT LIVING WITH YOU
GENERAL INFORMATION Name (as it appears on insur card) Address City State Zip Home phone Cell Email Marital status DOB SS# Employer Work # Parent name (if minor) IN CASE OF AN EMERGENCY NOT LIVING WITH
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
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
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
Date of Visit / / Date of Birth / / Age
New Patient Health Questionnaire Date of Visit / / Date of Birth / / Age Email Race: Non-Hispanic Hispanic Preferred Language: English Other Do you have advanced directives: living will, power of attorney
Patient registration
Patient registration Name: DOB: Sex: Date: Who referred you to our office? Other Physicians you see: Occupation: Place of Employment: Marital Status (Please Circle): Single Married Separated Divorced Widowed
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
NEW PATIENT VISIT QUESTIONNAIRE
HeartHealth A Program of the Dalio Institute of Cardiovascular Imaging NEW PATIENT VISIT QUESTIONNAIRE Name: Date of Birth: / / Address: City: State: Zip: Home Phone #: Work Phone #: Cell #: Email: Preferred