Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Securifi #: Sex: trtr Male trtr Female Home Phone #: Mobile phone #: Email Address: Widowed In Case of Emergency Please Contact: Name: phone #: Employer Information Employer Name: Retired Marital Status: trtr Single trtr Married trtr Divorced ED Relationship to patient: Employment Status: Etr Full Time trtr Part Time trd Student Dtr Address: City: State: Zip Code: Work Phone Number: Patient Occupation: Primary Insurance Plan Name: Insured Name: Date of Birth: Soc Sec #: lnsured Employer: Employer Phone #: Secondary fnsurance Plan Name: lnsured Name: Date of Birth: Soc Sec #: Insured Employer: Employer Phone #: Physician fnformation Name of Referring Physician: Family Doctor: Telephone Number: Telephone Number: I)o you have a Preferred Pharmacy? trtr yes Name of Pharrnacy: Phone #: If yes, please provide the following information:
Vascular Surgery Clinic Name: Date: Date of Birth: Height: Weight: Medication (prescription, over the counter, and vitamins) MEDICATION DOSE FREQUENCY MEDICATION ALLERGY? tj NE LJ NAMEOF MEDTCATION REACTION NAME OF FOOD ALLERGY REACTION
MEDICAL HISTORY Vascular Surgery Clinic Please circle *" or "' Eo any Past or current medical condifions Kidney Problem CV: Atrial fibrillation CV: Aortic Stenosis CV: Coronary Arterial Disease CV: Heart Failure NEURO: Dementia NEURO: Seizure Disorder ENDO: Diabetes Mellirus Type2 PULM: Asthma PULM: Chronic Obstrucdve Pulmonary Disease/Emphysema Bleefing Disorder HEME:Anemia HEME: Deep Vein Thrombosis HEME: Leukemia HEME: Pulmonary Embolism ID: MRSA Hx Numbness High Cholesterol CV: Myocardial Infarcrion PSYCH: Depression D*g Abuse GI: Hepatitis C, Chronic GI: Peptic Ulcer Disorder RENAL: Insufficiency/Chronic Kidney Disease
Vascular Surgery CIinic Arrhythmia Stroke Temporary Blindness Speech Difficulty CV: Hyperlipidemia CV: Hypertension Liver Cirrhosis ENDO: H)pothpoid ENDO: Obesity PULM: Obstructive Sleep Apnea RENAL: End Stage Renal Disease SURGICALHISTORY DATE App.ndecEomy C-Section CABG (Coronary Blpass Graft) CholecystecEomy (Lup) Cholecystecromy (Open) Hysrerectomy Total Hysterecromy PTCA,Hx (Coronary Angioplasty)
\retn SOCIALHISTORY Vascular Surgery CIinic NEVER NEVER DAILY WEEKLY MONTHTY WINE BEER OTHER Do you smoke? Number of years Packs per dry Interesred in quitcing? How long you smo ed before quitting Number of years Packs per d^y Do you consume alcohoh How often? Which alcoholic beverage? Dn g abuse? LEARNING PREFERENCE What is your learning preference? (Circle all that applies) LISTENING READING DEMONSTRATION PICTURES/YIDEOS OTHER (Please Spectfy) : FALL RTSK Have you fallen in rhe last 30 days? (Please circle one) I
EXANI VEIN Vascular SurBery Clinic FAMILYHISTORY Heart Disease Stroke Aneurysm Other Vascular Problems (Please specify) Age of occurrence Relationshlp Mother Father Slste r Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Other ReYiew of Systems: A.re you currently having problems with any of the following? (y1'es, N:no) Constitutional Symptoms: Cardiovascular Symptoms: Musculoskeletal Symptoms: Y N Fever Y N Chest Pain on Exertion y N Muscle Aches Y N Chills Y N A Pain on Exertion Y N Muscle weakness Y N Weight Gain ( lbs) Y N Shorrness of Breath Y N weight Loss ( lbs) Y N Heart Palpitations Y N Decreased Appetite Y N Heart Murmurs Ey. S) -ptoms: Y N Calf or Jaw Pain Y N Change in Vision Y N Ankle Swelling Y N Eye Pain Respiratory Symptoms: Y N Ey* Irritation Y N Cough Ear, Nose, and Throat: Y N Wheeztng Y N Decreased Hearing Y N Vertigo Y N Ringing in the Ears YN Nose/SinusProblems YN Vomiting Y N Nose bleeds Y N Sore Throat Y N Ditficulty Speakiog Y N Bleeding Gums Y N Shortness of Breath Y N Joint Pain Y N Back Pain Y N Swellirrg in Arms/Legs Y N Difficulry Walking fntegumentary Symptoms: Y N Dry Skin Y N Jaundice Y N Rashes Y N Discoloration Gastrointestinal S-vmptoms: Y N GrowthLesions Y N Nausea Y N [Jlcers Aller gic/im m u nolo gic : Y N Vomiting Blood Y N Runny Nose Y N Abdorninal Pain Y N Sinus Pressure Y N Change in Appetite Y N Itching Y N Heartburn Y N Hives Y N Teeth Abno alities Y N Black or Tarry Stools y N Frequent Sneezing Endocrine Symptoms: Y N Fatigue Y N Cold Intolerance Y N Hair Loss Y N Increased Hair Growth Y N Irreg Menstrual Cycle Y N Increased Thirst H e m atolo gic/l y'm p hatic : Y N Swollen Glands Y N Bruising Y N Excessive Bleedirg Neurologic Symptoms: Y N Loss of Consciousness Y N Slurred Speech Y N Weakness Y N Numbness Y N Headaches Y N Memory Lapse / Change Y N Loss of Balance / Falls Y N Restless Legs Client's Signature Date