PATIENT INFORMATION. Are we currently seeing one of your family members at our practice, or have we previously? YES patient s name:

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Transcription:

PATIENT INFORMATION Date Name Address First Middle Last City State Zip Home # Cell # Check this box to authorize text messaging for confirming and reminders Email Check this box to authorize our office to email you Employer Work # Emergency Contact Phone # Marital Status_ SSN Birthdate Sex M/F (please circle) Preferred Language: English Spanish Russian Other Ethnicity: Hispanic/Latino Non-Hisp. Race: White Native American African American Asian Other Referred by Family Physician Are we currently seeing one of your family members at our practice, or have we previously? YES patient s name: NO If so, Name Address GUARANTOR INFORMATION First Middle Last State Zip Home # Employer Work # SSN Birthdate Sex INSURANCE INFORMATION Primary Insurance Subscriber Subscriber ID Group # Co-Pay Amount Secondary Insurance Subscriber Subscriber ID Group # Co-Pay Amount City I herby authorize my insurance benefits to be paid directly to the doctor. I authorize the doctor or the insurance company to release any information required for this claim. I am financially responsible for any balance due and any collection costs should action need to brought to collect payment. Signature Date Please turn page over and continue

Please turn page over and continue

Patient Name: Date: MEDICATION LIST Please list all of your current medications that you take regularly or occasionally, nonprescription medications, vitamins, and supplements. Please include dosage and frequency of taking for each medication. Include medicines discontinued or changed in past 8 weeks. START DATE NAME OF MEDICATION DOSAGE AND DIRECTIONS REASON FOR TAKING DATE STOPPED Please list drug and food allergies Please turn page over and continue 3

Patient Name: Date: 12401 E Sinto Ave. Spokane Valley, WA 99216 P: 509-922-2055 / F: 509-922-2307 Paul M. Craig, MD Amelia Williams, PA-C Clinton S. Poppel, MD Lindsay Adams, ARNP Patient Health History Questionnaire Name: First MI Last Date of Birth: / / Age: Primary Care Physician: Brief Reason for Visit today: Past Medical History (Have you had any of the following medical problems or surgeries?): High blood pressure Y N Irregular heart rhythm Y N Angina Y N Heart attack Y N Congestive heart failure Y N Heart Angioplasty Y N Heart Stent Y N Heart bypass Y N Heart valve replacement Y N Aortic aneurysm repair Y N Asthma Y N Emphysema Y N Pneumonia Y N Obstructive Sleep Apnea Y N Using CPAP Y N Barrett s esophagus Y N Stomach ulcers Y N Pancreatitis Y N Gallstones Y N Liver disease Y N Hepatitis Y N Cirrhosis Y N Irritable Bowel Syndrome Y N Wheat intolerance Y N Milk intolerance Y N Crohn s disease Y N Diverticulosis Y N Diverticulitis Y N Ulcerative colitis Y N Colon polyps removal Y N Colon polyps PRIOR to age 50 Y N Stroke Y N Seizures Y N Migraines Y N Anxiety Y N Depression Y N Alcoholism Y N Diabetes Y N Thyroid disease Y N Kidney stones Y N Poor kidney function Y N Reflux disease Y N Esophageal stricture Y N Colon cancer removal Y N Colon cancer removal PRIOR to age 50 Y N Breast cancer removal Y N Ovarian cancer removal Y N Uterine cancer removal Y N Skin Cancer removal Y N Appendix removal Y N Anti-Reflux surgery Y N Stomach surgery Y N Pancreas surgery Y N Gallbladder removal Y N Bowel obstruction repair Y N Colon surgery Y N Hemorrhoid surgery Y N Hernia repair Y N Please turn page over and continue 4

Patient Name: Breast surgery Y N Breast biopsy Y N Tubal ligation Y N Complete Hysterectomy Y N Partial Hysterectomy Y N Joint replacement Y N Organ transplant Y N Prostate Surgery Y N Caesarean Section Y N Bladder Suspension Y N Spleen Removal Y N Gastric Bypass/Banding Y N Date: Social History (Please answer the following questions; use your best estimates): WHAT IS YOUR MARITAL STATUS? Single Partnered Married Separated Divorced Widow ARE YOU WORKING? Y N Occupation? (For the following, please describe best estimate on weekly use over the past 6 months) DO YOU DRINK COFFEE? Y N How much and often? DO YOU DRINK SODA? Y N How much and often? DO YOU EAT DAIRY PRODUCTS? Y N How much and often? DO YOU USE TOBACCO PRODUCTS? Y N DO YOU USE MARIJUANA OR CANNABIS PRODUCTS? Y N DO YOU DRINK ALCOHOL? Y N How much and often? HAVE YOU LEFT THE US IN PAST 6 MOS? Y N Where to and when? HAVE YOU HAD A BLOOD TRANSFUSION? Y N When? DO YOU HAVE A HISTORY OF RECREATIONAL DRUG USE? Y N Explain? Family Medical History Is there a history of the following in your family EXCLUDING YOURSELF? (Please circle Y or N, and indicate who): STOMACH CANCER SMALL INTESTINE CANCER PANCREATIC CANCER KIDNEY OR URETER CANCER BLADDER CANCER ULCER DISEASE ULCERATIVE COLITIS CROHN S DISEASE DIVERTICULOSIS GALLBLADDER DISEASE LIVER DISEASE COLON POLYPS COLON CANCER BREAST CANCER UTERINE CANCER OVARIAN CANCER Do you have any first-degree relatives PRIOR to age 50 with the following? (Please circle) Colorectal Cancer Uterine Cancer Ovarian Cancer Stomach Cancer Small Intestine Cancer Urinary Tract Cancer Bile Duct Cancer Pancreatic Cancer Brain Cancer Do you have 3 or more relatives with Colorectal cancer? Y Please turn page over and continue 5 N

Patient Name: Date: GI System Review: (Please indicate if you had any of the symptoms listed below left in the past 6 months. Use space to right to indicate when this occurred): Weight Loss > 10lb Y N Fever Y N Loss of appetite Y N Nausea Y N Vomiting Y N Heartburn Y N Chest Pain Y N Trouble swallowing Y N Painful swallowing Y N Abdominal pain Y N Increased gas Y N Change in bowels Y N Diarrhea Y N Constipation Y N Stool incontinence Y N Mucous in stool Y N Blood in stool Y N Black stool Y N Light-colored stool Y N Fat droplets in stool Y N Abdominal swelling Y N Rectal pain Y N Anal pain Y N Non GI System Review (On the lists below, circle problems you have): FATIGUE GENERAL WEAKNESS CHILLS NIGHT SWEATS DIFFICULTY SLEEPING EYE PAIN DRY EYES YELLOW EYES VISION CHANGE FREQUENT NOSE BLEEDS HEARING LOSS SORE THROAT HOARSENESS SINUS PROBLEMS NON-HEALING MOUTH SORES WHEEZING COUGH WITH COLORED SPUTUM COUGH WITH BLOOD DRY COUGH SHORTNESS OF BREATH HEART MURMUR HEART RACING COLD HANDS/FEET CALF OR LEG PAIN SHORTNESS OF BREATH ON EXERTION GOUT COLD INTOLERANCE INCREASED THIRST INCREASE URINE HEAT INTOLERANCE NOW PREGNANT BREAST CHANGES CHANGED MENSES HOT FLASHES DECREASED LIBIDO BLOODY URINE PAINFUL URINE WEAK URINE URINE AT NIGHT INCREASED FREQUENCY OF URINATION GENITAL PAIN GENITAL LUMP GENITAL SORE GENITAL DISCHARGE INTERCOURSE PAIN CHANGED GLANDS BLOOD CLOTS EASY BRUISING ABNL BLEEDING HIV POSITIVE DIZZINESS HEADACHES NUMBNESS UNUSUAL FORGETFULNESS MENTAL ILLNESS JOINT PAIN JOINT SWELLING TREMORS UNSTABLE WALKING MUSCLE WEAKNESS CHRONIC RHINITIS FREQUENT COLDS HAY FEVER ITCHY EYES HIVES RASHES SKIN COLOR CHANGE ITCHING DRY SKIN ABNORMAL MOLES 6

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