Josette E. Spotts, MD, FACS 1485 W. Warm Springs Road, Suite 105 Henderson, NV 89014 Tel: 702.990.6360 Fax: 702.990.6363 Patient Name: Date: Age: Referred by: Reason for visit:
Patient Name: Medical History Please check if you have a history of any of the following: Congestive heart failure Heart attack Arrhythmia Mitral valve prolapse Hypertension Stroke High cholesterol Valvular disease COPD Emphysema Pulmonary embolism Sleep apnea Chronic bronchitis Kidney disease Kidney failure Chronic UTI Gastritis Chron s disease Peptic ulcer Hepatitis Irritable bowel syndrome GERD Hiatal hernia Anemia Blood clots Bleeding disorder Arthritis Fibromyalgia Diabetes Thyroid Disease Osteoporosis Osteopenia Parkinson s disease Seizure disorder Migraine headaches Multiple sclerosis Dementia Bipolar Cancer Surgical History Surgery Date Surgery Date 1) 4) 2) 5) 3) 6) Previous Blood Transfusions: Y N Did you have a reaction? Y N If yes, what was the reaction?
Please list drug allergies and reactions: 1) 3) 5) 2) 4) 6) Medications-Vitamins-Supplements Name: Dose: Name: Dose: Social History Are you currently: Employed Unemployed Retired Disabled Occupation: Circle One: Single Married Divorced Widowed Separated Have you ever smoked? Yes No Average pack per day: If yes, your age when you started? Date quit (if applicable): Do you drink alcohol? Yes No If yes, how much per week? Use of recreational drugs: Yes No If yes, what type? Heart disease High cholesterol High blood pressure Stroke Diabetes Bleeding disorders Blood clots Family History Please check all that apply Yes Relationship
Family Cancer History Family Member Type of Cancer Age Living Deceased OB/GYN History Age of first period: Date of last menstrual period: Are you currently pregnant? Yes No # of pregnancies # of live births Age of first pregnancy History of breast feeding? Age of first live birth Yes No History of hormone replacement therapy? History of birth control pills? Yes No Yes No If yes, how long were you on the following: Birth control pills Hormone replacement therapy Please check if you CURRENTLY have any of the following symptoms: Fatigue Weight change Insomnia Hot flashes Sinusitis Ringing in ears Visual changes Difficulty swallowing Hoarseness Sore throat Vomiting Heartburn Constipation Diarrhea Hemorrhoids Burning with urination Blood in urine Need to urinate at night Incontinence Vaginal discharge
Chest pain Palpitations Ankle swelling Cough Shortness of breath Wheezing Abdominal Pain Nausea Depression Vaginal dryness Irregular periods Painful periods Heavy periods Muscle pain Back pain Skin rash Anxiety
LIMITED ENGLISH PROFICIENCY OF LANGUAGE ASSISTANCE SERVICES FOR NEVADA ATTENTION: If you speak any of the following languages, language assistance services, free of charge, are available to you. Call 1-877-261-6608 for more information. Amharic: ትኩረት: እርስዎ የ አማርኛ ተናጋሪ ከሆኑ የቋንቋ ድጋፍ አገልግሎቶች ያለ ክፍያ በነጻ ተዘጋጅልዎታል:: በ1-877-261-6608 ይደውሉ:: Arabic ملحوظة: إذا كنت تتحدث اللغة العربية تتوافر لك خدمة المساعدة اللغوية بالمجان. برجاء االتصال ب 1-877-261-6608. Chinese: 注意 : 如果您讲中文, 我们可以为您提供免费语言协助服务 请拨打 1-877-261-6608 German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufen Sie 1-877-261-6608. Japanese: ご注意 : 日本語でお話しになりたい場合は 無料の言語支援サービスをご利用いただけます 1-877- 261-6608にお電話ください Russian: ВНИМАНИЕ: Если вы говорите по-русски, вам предложены бесплатные услуги перевода. Звоните по телефону 1-877-261-6608. Spanish: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llamar al 1-877-261-6608. Thai: โปรดทราบ: หากค ณพ ดภาษาไทย บร การให ความช วยเหล อด านภาษาพร อมให บร การแก ค ณโดยไม ม ค าใช จ าย โทร 1-877-261-6608 Vietnamese: CHÚ Ý: Nếu quý vị nói Tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho quý vị. Hãy gọi 1-877-261-6608. French: ATTENTION : Si vous parlez français, des services d'aide linguistique, vous sont proposés gratuitement. Appelez le 1-877-261-6608. Ilocano: PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan iti 1-877-261-6608. Korean: 안내 : 한국어통역지원서비스를무료로 제공해드리고있습니다. 지원이필요하시면, 전화 1-877-261-6608 로문의하시기바랍니다. Samoan: FAAALIGA: Afai e te tautala Faa-Samoa, o loo maua fesoasoani mo tautua tau gagana, e lē totogia mo oe. Telefoni i le 1-877-261-6608. Tagalog: ATENSYON: Kung nagsasalita ka ng Tagalog, ang mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit mo. Tumawag 1-877-261-6608. Urdu: توجه: اگر فارسی صحبت میکنید خدمات ترجمه به صورت رایگان در اختیارتان قرار میگیرد. با -1-877-261 6608 تماس بگیرید.