Patient Label (Office Use)

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Transcription:

Name: Patient Label (Office Use) VVMC Diversified Services Health History Survey And Contact Information Please provide the following information so we may contact you as needed. We may contact you to remind you of an appointment or to convey results such as lab or x-ray. If you do not wish to have this information shared with anyone, or left on your voicemail, please indicate below. If you are the divorced/separated parent/guardian of a patient who is 17 years or younger, please indicate if the other parent may receive information. Please write in your preferred contact number(s) and choose one corresponding box indicating your contact preference below. Preferred Telephone: H: C: OK to leave a detailed message Leave a message with call back number only Do not leave any message/information Written Communication: OK to mail to my house OK to mail to my work/office OK to fax to: OK to email to: List below any person who may receive information Name(s): Phone Number(s): Emergency Contact & Relation: DOB: Emergency Contact Phone(s): Emergency Contact Address: Patient prefers to be called (nickname, other name): Race: Patient Declines Ethnicity: Patient Declines Primary Language: DOB: Physical Address: Mailing Address: Patient/Parent/Guardian Signature: Date:

Primary Care Provider Referring Physician Reason for Visit/Chief Complaint Preferred Pharmacy Location Medications (Including over-the-counter & dietary supplements) Name of Drug Dosage How often Reason for taking Allergies Drug Reaction Food Reaction Women Only Yes No Could you be pregnant? Date of last menstrual period? Last pap smear? Post-menopausal? Are you or have you taken birth control pills? General Past Medical History Yes No Fever-recurring Shaking Chills Weight loss or gain - Unexplained Weakness Fatigue Exercise Intolerance

Body System Current or Past History Yes No EYES/ EARS/ NOSE/ Difficulty Swallowing THROAT CARDIOVASCULAR RESPIRATORY GASTROINTESTINAL GENITO-URINARY (GU) Hearing Problems Nose bleeds Sinus/Hay Fever Problems Vision Problems Chest Pain or Pressure Cholesterol Disorder Coronary Artery Disease/ Heart Attack/ When? Stents or Bypass Surgery Prior EKG When Where High Blood Pressure Irregular Heart Rate/ Palpitations Heart Racing Leg/ Ankle Swelling Lightheadedness/ Fainting Pace Maker/ Defribrillator -? Brand Murmur Stroke/ TIA Asthma Cough Unexplained Shortness of Breath Sleep Apnea CPAP - settings Snoring/Poor Sleep High Altitude Sickness COPD/ Emphysema Abdominal Pain/ Distention Nausea/Vomiting/Diarrhea Difficulty Swallowing Indigestion/Heart Burn/ Acid Reflux Gall Bladder Problems Liver Problems/Hepatitis Blood in Urine Kidney Stones Burning Sensation Leaking Urine Recurrent Infections/ UTI s Frequent Urination Erectile Issues ( E.D. ) Number of Pregnancies Miscarriages Birth Control Method

Body System Current or Past History Yes No MUSCULOSKELETAL SKIN NEUROLOGICAL ENDOCRINE/HEMATOLOGY MISC Arthritis Gout Muscle or Joint Pain (Acute/Chronic) Orthopedic Surgery Physical Disabilities Open Cuts or Sores Healing Problems Eczema/Psoriasis MRSA (Methicillin Resistant Staph) Rashes Weakness Stroke/ TIA/ Mini Stroke Seizures Loss of Balance Light Headedness/Fainting Headaches/Migraines Anemia Bleeding Problems/Easy Bruising Diabetes Excess Thirst Liver Problems/Hepatitis/HIV Thyroid Problems Weight Gain/Loss Anesthesia Problems Anxiety/Increased Levels of Stress Depression Past Surgical & Medical History/Hospitalization Year

Family History: Children: # Alive # Deceased Medical Problems/Onset Age Mother: Current Age Deceased @ Medical Problems/Onset Age Father: Current Age Deceased @ Medical Problems/Onset Age Brothers: Medical Problems/Onset Age Sisters: Medical Problems/Onset Age Social History: Profession Married (Spouse Name) Single Divorced Widowed Do you ever use Tobacco products? Y/N Packs/day Cans/wk Years Year Quit Alcohol frequency Y/N Beer Wine Liquor Days/Week Drinks/Day Recreation Drugs Y/N Type Frequency of use Local Resident Y/N Elevation of home Days/year at home Elev. Home 2 Days/year at Home 2 Do you exercise? Y/N Type Days/week Exercise Intolerance Y/N Type of Diet Regular Diabetic Vegetarian Calorie Restricted Low Salt Plant Based (no animal products) Servings of vegetables/day Servings of fruit/day Are you interested in regular health maintenance and prevention of disease? ***************************************************************************************************************************** Your signature below indicates all information is accurate to the best of your knowledge. Patient / Parent / Guardian Signature (sign above) Today s Date FOR OFFICE USE ONLY Physical Exam Height Weight BMI BP Pulse Respiration Temperature 02 SAT on room air/ L

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