Branko Radisavljevic, M.D.

Transcription

1

2 Today's Date: MONTH Branko Radisavljevic, M.D. CAY YEAR PERSONAL DATA Name: Address: Home: ( ) Work: ( ) Mobile: ( MEDICAL HISTORY ZIP: OK to leave msg? Date of Birth: MONTH CAY YEAR Occupation: Highest Education Level Completed (check one): o Elementary school o Master's Degree D High school D Associate's Degree D Bachelor's Degree D Doctorate D Technical/trade school D Other: Marital Status: D Single D Married D Divorced D Separated D Widowed Are you currently under the care of a physician(s) or clinician(s)? Name of Physician or Clinician: Address: If yes, please complete the following: Name of Physician or Clinician: Address: ZIP: ZIP: Do you have or have you ever had any of the following illnesses? (Please check all that apply) D High Blood Pressure D Gonorrhea D Tuberculosis D Diabetes D Syphilis D Stroke D Cancer D Thyroid Disease o Other Hormone Disease D Alcoholism / Drug Abuse D Epilepsy D Peptic Ulcer (Stomach Ulcer) o Colitis D Meningitis or Encephalitis D Rheumatic Fever D Asthma o Birth Defect D Other: What is your current weight? (If you do not know, please estimate): lbs. What is the most you have ever weighed? lbs. What is the least you have ever weighed? lbs. How tall are you? ft. in. When? From _ to MONTH YEAR MONTH YEAR When? From to MONTH YEAR MONTH YEAR

3 Have you ever been hospitalized (Non-psychiatric Addmissions)? o Yes D No If yes, please complete the following: Month / Year Doctor's Name Name of Hospital Reason Have you had surgery or been advised to undergo surgery? If yes, please complete the following: Month / Year Doctor's Name Name of Hospital Operation or Procedure Have you had any of the following injuries? (Please check all that apply and provide details in blanks) D Head Injury D Concussion (Knocked Unconscious) D Broken Bones D Severe Cuts or Lacerations D Severe Burns (2 nd or 3 rd Degree) D Food Poisoning D Chemical or Drug Poisioning D Other Do you have any of the following allergies? (Please check all that apply and describe how you are affected in blanks) D Penicillin D Other Have you recently had any of the following tests? (Please check all that apply) D Physical Exam o Blood Test D Chest X-Ray Month / Year / D Tuberculosis Skin Test (PPD) o Electrocardiogram (EKG) o Brain Scan or EMI DEEG Where Results Do you use or have you ever used any of the following? (Please check all that apply) D Laxatives D Cigarettes/Tobacco D Alcohol o Sleeping Pills Amount of Current Usage D Marijuana o Cocaine o Methamphetamine (Speed) o Opiates (Heroin, Prescription) Most Ever Used

4 Do you currently take any medications? Name of Medication: If yes, please complete the following: Dosage (Example: 150 mg twice daily) Do you use or have you ever used any of the following? (Please check all that apply) D Dilantin, Tegretol, L-Dopa, Cogentin or Artane o Valium, Librium, Serax, Dalmane, Tranxene or Ativan D Sinequan, Tofranil, Elavil or Meprobamate D Lithium D Thorazine, Mellatill, Stelazine, Moban or Serentil D Phenobarbital, Seconal, Tuinal or other barbiturates When Amount oamphetamines, Methamphetamine, Ritalin, Adderall or other stimulants D Heroin, Codeine, Methadone, Percodan, Dilaudid, Talwin, Darvon or Demerol D Quaaludes, Placidyl or other sedatives D Cocaine or crack cocaine D LSD, Mushrooms, Psilocybin or other hallucinogens o Other: When Amount PSYCHIATRIC HISTORY Have you ever received psychiatric or psychological treatment? If yes, please complete the following: Year Doctor's Name Hospital or Clinic Reason Medication(s) Used (if any) Have you attempted suicide in the past? If yes, please complete the following: Year Method of Attempt What happened afterwards? FAMILY HISTORY If any members of your immediate family are deceased, please check the box and provide the age and cause of death. If the person is still alive, simply write in his or her current age. D Mother D Father D Brother 1 D Brother 2 D Brother 3 D Sister 1 D Sister 2 D Sister 3 Age Cause of Death (if applicable) Age Cause of Death (if applicable) D Spouse 1 D Spouse 2 D Child 1 D Child 2 D Child 3 D Child 4 D Child 5 D Child 6

5 Do any of your immediate family members suffer with any of the followin!, now or in the past? (Check all that ap Jly) Moth. Fath. Bro 1 Bro2 Bro 3 Sis 1 Sis 2 Sis 3 Spa 1 Spa 2 Chi 1 Chi 2 Chi 3 Chi 4 Chi 5 Chi 6 Cancer Tuberculosis Diabetes Hioh Blood Pressure Stroke Heart Attack or Cardiac Disease Epilespy or Convulsions Nervous Breakdown Severe Deoression or Manic-Deoression Alcoholism Suicide or Suicide Attemot Drug Abuse Birth Defect or Genetic Disorder Thvroid Disease Other Hormone Problem Migraine Headaches Other: Are you currently experiencing any of the following medical symptoms? (Please check all that apply) o Lumps Anywhere o Double Vision or Poor Vision o Difficulty Hearing o Fainting or Blackouts o Convulsions D Paralysis D Dizziness D Thyroid Problem (Goiter) D Skin Problem D Constipation D Diarrhea o Cough or Wheeze o Chest Pain o Spitting up or Vomiting Blood o Shortness of Breath o Heart Flutter or Palpitation o Swollen Hands or Feet D Visual Hallucinations D Fever, Sweat or Chills D Unusually Excessive Thirst D Urine Problems or Blood in Urine D Stomach Pain or Stomach Ulcer D Blood in Stool o Indigestion, Gas or Heartburn o Change in Appetite or Eating Habits o Trouble Sleeping o Sexual Problems o Weight Loss or Gain o Depression D Thoughts of Suicide D Problems with Memory D Problems Thinking or Concentrating D Weakness or Tiredness D Joint Pain D Audio Hallucinations o Other: FEMALES ONLY: What was the date of your last menstrual period? / MONTH DAY YEAR Number of Pregnancies: Number of children born alive: Number of miscarriages and stillbirths: Number of abortions: Do you use any contraceptive method? If yes, which one? Have you had a Pap smear in the past year? o Yes o No Do you regularly examine your breasts for lumps? o Yes o No Patient Signature Patient Name Printed Date