Breast implants Breast reduction surgery Breast biopsy Breast lumpectomy Chest reconstruction Other:

Similar documents
Welcome to About Women by Women

University Gynecologic Oncology Associates

Adult Health History

Heart Murmur Chest Pain Palpitations Swelling of feet Shortness of breath

Lehigh Valley Physician Group

New Patient History. Patient Name: Date of Birth: Reason for Today s Visit: Today s Date: Who is your Primary Care Physician (PCP)?

COMPREHENSIVE NEW PATIENT QUESTIONNAIRE

MGH Beacon Hill Primary Care New Patient Form

Personal Health History

Adult Health History for NEW Patients

PATIENT HISTORY RECORD FACULTY INTERNAL MEDICINE. Date of Appt: / / Name: Date of Birth: / / Last First Middle

Adult Health History New Patient

Primary Care Clinic Adult Patient Demographics

IN CASE OF AN EMERGENCY NOT LIVING WITH YOU

USF Physicians Group University of South Florida, College of Medicine Department of Family Medicine

Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address

Women s Health. Allergies Medication, Food, or Substance (List below) What happens? (Symptoms or reactions) When did this occur?

Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code

Comprehensive Patient History Form

Patient History Form

Preventive Care Risk Assessment

NOTICE TO OUR PATIENTS

NEW PATIENT QUESTIONNAIRE

An affiliate of Saint Mary's Health System FRANKLIN MEDICAL GROUP, PC. NEW PATIENT INTAKE FORM. Last Name: First Name: DOB: Age:

Medical History Form

New Patient History Form (Age 18 and over)

NEW PATIENT INFORMATION FORM

ALLERGIES. If yes, please list the food and non-medication (i.e. latex) allergies and type of reaction you had: MEDICATIONS

Personal Health Risk Appraisal

This form is long! Please feel free to have the doctor or medical staff help you to complete it if you need any assistance at all.

DEPARTMENT OF MEDICINE Outpatient Intake Form

New Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( )

NEW PATIENT HISTORY. Primary Care Physician Preferred Pharmacy Pharmacy address Phone. Reason for today s visit. Pregnancies abortions miscarriages

Christine Chai, M.D. 901 Dover Drive, Suite 214 Newport Beach, CA 92660

Female Patient Questionnaire & History

2017 Preventive Health Care Guidelines Free preventive care to help you be your healthiest.

Patient Health Forms

Jeri Shuster, M.D., P.A.

DEPARTMENT OF MEDICINE Outpatient Intake Form

THE OB/GYN CENTRE NEW PATIENT HISTORY

2017 Preventive Health Care Guidelines Free preventive care to help you be your healthiest.

GIDEON G. LEWIS, M.D.

Medicare Annual Wellness Visit Patient History

New Patient Questionnaire. Name DOB Date

MedStar Medical Group at Forest Hill 1517 Rock Spring Road, Suite C Forest Hill, Maryland Phone (410) Fax (410)

Clinic Adult Patient Demographics

Initial Consultation

Female Patient Questionnaire & History

Inflammatory Bowel Disease Medical Exam Questionnaire

Medical History Form

Please list current medications Include Herbal and over the counter medications Include dose and how many times a day drug is taken 1. 6.

Patient Profile Patient Name: DOB: Address: City: State: Zip: Spouse/Significant Other: Children's names and ages: Patient Employer: Address:

Female New Patient Package

Preventive Care Coverage

MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire

PRIMARY CARE (719)

Women's Health, Naturally Fertility Questionnaire

SCHNEIDER MEDICAL GROUP, PA History Intake Form (Please Print)

Name: Date of Birth: Age: Address: City State Zip

Address Street Address City State Zip Code. Address Street Address City State Zip Code

INSURANCE DISCLAIMER

Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX

Health Questionnaire

Do you currently have a family physician?: If not, where have you been getting health care?:

Female New Patient Package

PATIENT HEALTH HISTORY

General Internal Medicine Clinic - New Patient Questionnaire

ALLERGIES 8. Have you ever had any allergic reaction (bad effect) to a medicine or shot?

We look forward to seeing you. Please feel free to call us with any questions.

WHAT IS THE MOST IMPORTANT INFORMATION I SHOULD KNOW ABOUT OGEN (AN ESTROGEN HORMONE)?

Optima Health. Adult Health Maintenance Guidelines. Guideline History. Original Approve Date 04/93

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

Adult Health History Form Preferred Name: 1

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

Marcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)

1405 NE Douglas Lee s Summit, MO Phone: Date: Fax: Female Information and Health Summary

Southern Maine Integrative Health Center Adult Intake Form

New Patient Information Form

Adult Health History for NEW Patients

Adult Health History for New Patient

Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:

Integrative Consult Patient Background Form

Preventive Services Explained

Initial History Form

Austin Fertility and Reproductive Medicine

MEDICAL HISTORY FORM FOR FOLLOW-UP

2017 Preventive Health Care Guidelines

DONE! You can now close the browser.

Ayurvedic Intake Form

Top Tier. Medical Breast Specialist, P.C.

Prevents future health problems. You receive these services without having any specific symptoms.

Patient Information: Date: Last Name: Street Address: City: SS #: First Name: Sex: M F Birthdate: Contact Information:

Billings Clinic Urogynecology. Patient Name: Date of Birth: Visit Date:

Female New Patient Package

Medication Allergies

Transcription:

New Patient Intake Form This form lets us get to know you and know how we can help. Not every question is important to everyone, but the more you can answer, the more we can help. If there is a question that makes you uncomfortable, skip it and discuss it during your visit. Thank you. Do you need help with this form? If you answered yes, please stop filling out the form and speak with a Front Desk staff member. Person filling out this form (if not the patient): Name Relationship to Patient Reason for your visit today: Routine exam Something is bothering me/i have something specific to discuss What medical problems do you have now or have you had in the past? Diabetes High Blood Pressure/hypertension High cholesterol Hepatitis A Hepatitis B Hepatitis C Other liver problems Pancreatitis Kidney failure Cancer Depression or anxiety Thyroid problems Migraines Blood clots Breast disease Allergies Asthma COPD or Emphysema Tuberculosis (TB) HIV or AIDS Addiction to: Other: What operations have you had in the past? Appendix removed Tonsils removed Gall bladder removed Hernia repaired Uterus removed (hysterectomy) Ovaries removed (oophorectomy) Breast implants Breast reduction surgery Breast biopsy Breast lumpectomy Chest reconstruction Other: Other than for surgery or childbirth, have you ever been in the hospital overnight? Has anyone in your family had any of the following? Diabetes Thyroid problems Blood clots/diseases High cholesterol Osteoporosis Breast cancer High blood pressure Parkinson s disease Colon cancer Heart attack Alzheimer s disease Ovarian cancer Heart surgery Mental illness Prostate cancer Stroke Alcohol/drug addiction Other: Are you allergic to any: medications foods animals/insects

What medicines (prescription and over-the-counter), vitamins, supplements and/or herbs do you take regularly? Name Dose When do you take it? What is it for? Do you often have trouble remembering to take medicines? Have you ever gotten a period? unsure Yes No How old were you when you first got your period? What was the date that your last normal period began? What are your periods like? I get one every days. It lasts for days. On my heaviest day, I use maxi pads/tampons. I get cramps with my period: If yes, how severe are they on a scale of 1 (low) to 10 (high)? _ Have you gone through menopause? unsure Yes No At what age? Have you had any bleeding since then? Have you ever taken hormone replacement? Do you currently take hormone replacement? If yes, what do you take? Estrogen/progesterone Estrogen alone Testosterone Other: Are you having any symptoms of menopause? If yes, which ones? Hot flashes Mood changes Vaginal dryness Insomnia other: When was your last vaccine for: HPV (Gardasil) Tetanus / TdaP Hepatitis A Hepatitis B Pneumonia (pneumovax) Chicken pox (varavax) Shingles (zostavax) date Did you receive childhood vaccinations? No I m not sure Yes

When was the last time you had a test for tuberculosis (TB)? Have you ever had a positive test for TB? If yes, did you complete 6 months of preventative treatment? If yes, which of the following symptoms do you have now? cough > 3 weeks unexplained weight loss coughing up blood drenching night sweats If no, have you had contact with someone known to have TB disease of the lung? Were you born in Asia, Africa, Latin America, or Eastern Europe? Have you spent more than 2 weeks in Asia, Africa, Latin America, or Eastern Europe in the past 2 years? Have you been in prison/jail in the past 5 years? Do you work with people who use drugs, are migrant workers, or are experiencing homelessness? Are you a health care worker? When was your last: Date Result HIV test unsure never Sexually transmitted infection test unsure never Hepatitis C test unsure never Bone density test unsure never Cholesterol test unsure never When was your last: Date Result Cervical Pap smear unsure never Anal Pap smear unsure never Mammogram unsure never Colorectal cancer unsure never Which test(s) you ve had: FOBT FIT Colonoscopy Other When was the last time you saw a dentist? How often in the past year have you had an alcoholic beverage? Daily or almost daily Less than monthly Weekly Never Monthly How often in the past year have you used an illegal drug or used a prescription medication for non-medical reasons? Daily or almost daily Less than monthly Weekly Never Monthly

Have you ever had sex with another person? In your lifetime your sexual partner(s) have been: (check all that apply) women transgender FTM genderqueer men transgender MTF other: Currently your sexual partner(s) are: (check all that apply) none women transgender FTM genderqueer men transgender MTF other: When was the last time you had sex with another person? In the past year, how many different sexual partner(s) have you had? Currently, how many sexual partner(s) do you have? Do you only have sex with each other? Are you practicing safer sex? Never Sometimes Always Do you think you or your sexual partner(s) may have a sexually transmitted infection right now? Are you having any difficulties with your sex life? Do you want to discuss this today? What sexually transmitted infection(s) have you had in the past? Gonorrhea Oral herpes Chlamydia Genital herpes Pelvic inflammatory disease Herpes through a blood test Syphilis Genital warts Trichomonas Other: Have you ever been pregnant? If yes, how many times have you been pregnant? How many abortions? How many premature births? How many miscarriages? How many full-term births? How many live children do you have now? Are you planning on getting pregnant? If yes, when? Do you or your partner(s) use any kind of birth control? If yes, what kind? Are you satisfied with this method? Could you or your partner(s) be pregnant today? What would you do if you or your partner(s) got pregnant? Not needed N/A Have you ever been non-consensually hit, slapped, kicked, or otherwise physically hurt by an intimate partner? If yes, when did this happen? Do you want to discuss this today? Have you ever been forced to have sexual activities against your will? If yes, when did this happen? Do you want to discuss this today?

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback