SAMIR PATEL, MD. Patient Medical History

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Transcription:

SAMIR PATEL, MD 285 Governor St, Providence RI 02906 Tel: (401) 992-4702 Fax: (425) 242-8368 www.samirpatelmd.com Today s Date / / Patient Name: Who referred you to this practice? Describe briefly your present problem(s)/symptoms: Please provide details regarding any outpatient psychiatric treatment/psychotherapy you may have had for the same problem(s) or other problems in the past: Are you currently in treatment with a mental health professional? Psychiatric Hospitalizations (include where, when, for what reason & psychiatric diagnosis) Have you ever had ECT? If yes, when and for what reason?

CURRENT MEDICATIONS Known Drug Allergies? Yes No If yes, to what? Please list any medications that you are currently taking. Also, include non-prescription medications, vitamins, supplements, and herbal remedies. Name of the Drug Dose (strength) How do you take it? (e.g 2 tabs once daily/ 1 tab three times a day) How long have you taken the drug? 2

PAST MEDICAL HISTORY Do you now or have you ever had: Diabetes High Blood Pressure High Cholesterol Thyroid Problems (hypothyroidism, goiter, Grave s Disease, etc) Health Problems (Heart Attack, Coronary Bypass, Coronary Stenting, etc) Heart Rhythm Problems (arrhythmias) Heart Murmur Malignancy (Cancer/leukemia) (type): Sleep Apnea Stroke or Mini strokes chronic bronchitis) Chronic headaches (e.g. migraine) Epilepsy (seizures) Frequent Falls Parkinson s Disease Lupus or other autoimmune conditions (e.g. Rheumatoid Arthritis, Psoriasis) Rheumatic fever Arthritis Glaucoma Stomach or peptic ulcer Irritable Bowel Colitis or Crohn s Disease Asthma COPD (emphysema or chronic bronchitis) Pulmonary embolism Anemia Jaundice Hepatitis HIV/AIDS Tuberculosis Kidney Disease Other Medical Conditions (please list): PERSONAL HISTORY Were there problems with your birth? Where were you born and raised? What is your highest education? Marital Status: Religious preference, if any What is your current or past occupation? Are you currently working? If yes, hours/week If not, are you: Retired Disabled Sick Leave Do you receive disability or SSI? Yes No If yes, for how long? Have you ever had legal problems? (specify) 3

FAMILY HISTORY Age, if living otherwise age of death, Medical and Psychiatric Problems Father Mother Siblings Children Extended Family Psychiatric Problems: Maternal Relatives Paternal Relatives Did anyone attempt or commit suicide in your family? SYSTEMS REVIEW In the past month, have you had any of the following problems? Constitutional Recent weight gain, how much Recent weight loss, how much Fever Fatigue/Malaise/Low energy Night sweats Nervous system Headaches Tingling and Numbness Fainting/Loss of consciousness Dizziness Gait changes/falls Memory Loss Eyes Vision loss Eye pain or redness Dry eyes Double/blurry vision Blood Easy bruising/bleeding Clots Stomach/Gut/Bowel Heartburn Nausea/vomitting Blood in vomit Blood in stool Black tar-like stool Increasing constipation Persistent diarrhea Stomach aches Muscles/Joints/Bones Joint pain/stiffness: where? Bone pain Pain in muscles Jaw pain Female reproductive Irregular periods Heavy periods No periods Abnormal pap smears Menopausal hot flashes 4

Ears Hearing loss Ringing in ears Ear pain Throat Difficulty swallowing Frequent sore throat Hoarseness Heart and lungs Chest pains Shortness of breath Rapid heart beat Palpitations Cough/sputum Swollen legs Fainting spells Skin/Nails Rash Redness Jaundice/yellowing Changes in nail shape/texture Blisters/bumps/nodules Kidney/Genital/Urinary System Frequent urinations Burning urination Blood in urine Incontinence Discharge from penis/vagina Psychiatric Depression Loss of pleasure Stress Excessive worrying Problems falling or staying asleep Loss of appetite Loss of interest in sex/sexual problems Excessive eating/food cravings Frequent crying Guilty thoughts Poor concentration Suicidal thoughts Scary or intrusive thoughts Compulsive behaviors Violent thoughts Hallucinations Excessive energy/restlessness Rapid speech Increased impulsivity/reckless behavior Paranoia Mood swings/emotional sensitivity Irritability/rage Other symptoms WOMEN S REPRODUCTIVE HISTORY Are you currently pregnant? Maybe or planning to Do you have regular periods? Have you reached menopause? At what age? Number of pregnancies: Number of miscarriages: Number of abortions: 5

HISTORY OF SUBSTANCE USE Drug Category (circle each substance used) Age when first used this? How many years did you use this?? When did you last use this? Are you currently using this? Alcohol Cigarettes/tobacco product Marijuana (joint, hashish, oil, edibles, other forms ) Synthetic Marijuana (Spice, K2, etc) Stimulants without prescriptions ( Ritalin, Adderall, Dexedrine etc) Cocaine, Crack Crystal Meth, Ice, Speed Benzos (Valium, Xanax, Ativan, Klonopin, roofies, etc ) Sedatives/Barbiturates (Amytal, Seconal, etc) Painkillers (oxycodone, methadone, vicodin, percodan, morphine, codeine, etc) Heroin (snorted, injected) Hallucinogens (LSD, PCP, Special K, mescaline, peyote, mushrooms, ecstasy) Inhalants (Glue, gasoline, aerosols, paint thinner, poppers, etc) Other: 6

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