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Transcription:

Page 1 of 5 Physicians: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Physicians: Samuel J. Tarwater, MD Travis J. Rutland, MD Ashwani Kapoor, MD Pathologist: Beth Rutland, MD 334-836-1212 phone 334-836-1888 fax 480 Honeysuckle Rd, Dothan, AL 36305 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Race White/Caucasian Native Hawaiian or Other Pacific Islander Black or African American Asian Hispanic or American Indian or Alaska Native Mixed Other Unknown Patient declines to provide information Ethnicity Hispanic or Not Hispanic or Patient declines to provide information Gender Male Female Other Preferred Language English Contact Preference Letter Telephone call e-mail Allergies Patient has no known allergies Patient has no known drug allergies Demerol IVP Dye Latex Penicillins Propofol Sulfa (Sulfonamides) Versed Immunizations

Page 2 of 5 Flu Vaccine Hep B PPD/TB Skin Test Pneumonia Vaccine

Page 3 of 5 Pharmacy Name: Current Medications Name Dose How taken? Diagnostic Studies/Tests Abdominal Ultrasound Sigmoidoscopy Barium Swallow Test for Blood in Stool Colonoscopy Upper Endoscopy/EGD CT Abdomen Esophageal Motility Study HIDA Scan Previous Procedures Appendectomy/Appendix Gastric Bypass Hysterectomy Heart Bypass Pacemaker Cholecystectomy/Gallbladder Heart Valve Replacement Paracentesis Colon Surgery Hemorrhoid Surgery Prostate Surgery Defibrillator Hernia Repair

Page 4 of 5 Past or Present Medical Conditions Anemia Anxiety/Depression Arthritis Atrial Fibrillation Barrett's Esophagus Bleeding Disorders Colon Polyps Blood Clots (DVT) Congestive Heart Failure Cancer Celiac Disease Cirrhosis Crohn's Disease Diverticulitis/Diverticulosis Gallstones GERD or reflux disease Diabetes (Insulin Dependent) Heart Attack Hemorrhoids Hepatitis C High Blood Pressure Irritable Bowel Syndrome GI Bleeding Diabetes (Non Insulin Dependent) Kidney Dialysis Liver Disease Pancreatitis Pulmonary Embolism Seizure Disorder Stroke Ulcer Disease Ulcerative Colitis HIV Social History Occupation: Marital Status Single Married Divorced Separated Widowed Civil Union Unknown Other Alcohol Type Quantity Number Frequency Tobacco Smoking Status Current every day smoker Smoker, current status unknown Current some day smoker Unknown if ever smoked Former smoker Never smoker Drug Use Type Quantity Number Frequency

Page 5 of 5 Family Medical History No knowledge of family history Health Status Cause of Death Diagnoses Gallstones Pancreas problems Liver disease Colon polyps Colon cancer Crohn's disease Ulcerative colitis Stomach ulcers Review Of Systems Constitutional chronic fatigue fever weight loss Integumentary bruising rash Hematologic/Lymphatic anemia blood disorders easy bleeding Musculoskeletal weakness back pain joint pain ENMT deafness dizziness mouth or throat sores hoarseness Respiratory asthma wheezing cough shortness of breath Cardiovascular chest pain palpitations Gastrointestinal diarrhea constipation heartburn stomach cramps nausea vomiting blood in stool blood on the tissue paper bloating jaundice gas trouble swallowing Genitourinary increased urinary frequency change in urine color prostate problems Neurological stroke numbness Psychiatric bad nerves depression

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