Little Rock Diagnostic Clinic Endocrinology - Patient Questionnaire

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Office Use only Doctor: LRDC Chart #: Appointment Date: Little Rock Diagnostic Clinic Endocrinology - Patient Questionnaire This information will become part of the medical record and is subject to federal privacy laws. Full Name: Date of Birth: E-mail address: Cell Phone: Circle all that apply: tobacco use high blood pressure diabetes heart disease Please describe the medical problem or reason that you are here for evaluation today. When did it start? How long does it last? Where is it located? How severe is it? How often does it occur? Aggravated by? Relieved by? Vitals This box will be completed by the nursing staff at the Provider s office Please DO NOT write. Ht WT Temp BP Pulse Resp Pulse ox

Please list the medications you are currently taking. Please include all over-the-counter and herbal medications (use back of page if needed): Medication Name Dosage How often Started Problem medication for Doctor who wrote Pharmacy Name and Address Do you get your medications for 30 days or 90 days at a time? (circle one) 30 days 90 days Please list any drug allergies or side effects (use back page if needed) When Drug Describe Reaction Immunizations (list date of last) Tetanus Pneumonia Shingles Flu List all the physicians that you are currently seeing: Physician Name Specialty Condition being treated Next Office Visit Would you like a copy of your visit sent to this doctor? 2 P a g e

Review of Systems- MEN ONLY Please check a box below for every question that applies to your current health General No Yes Urinary No Yes Skin No Yes Chills Dribbling Brittle hair Fatigue Painful urination Brittle nails Fever Blood in urine Hair loss Night sweats Excessive urination Excessive hair growth Tired Slow stream Hives Weight gain Increased frequency Itching Weight loss Unable to hold urine Mole changes Trouble emptying bladder Rash Skin lesion Head/Neck No Yes Reproductive No Yes Ear drainage Erection problems Ear pain Discharge from penis Musculoskeletal No Yes Eye discharge Decreased libido Back pain Eye pain Joint pain Hearing loss Joint swelling Nasal drainage Metabolic No Yes Muscle weakness Sinus pressure Cold intolerance Neck pain Sore throat Heat intolerance Visual changes Always thirsty Always hungry Blood/lymph No Yes Easy bleeding Respiratory No Yes Easy bruising Chronic cough Neurological No Yes Enlarged lymph nodes Recent cough Dizziness Known TB exposure Numbness in arms/legs Shortness of breath Weakness in arms/legs Immunity No Yes Wheezing Trouble walking Contact allergy Headache Environmental allergy Memory loss Food allergy Heart No Yes Seizures Seasonal allergy Chest pains Tremors Leg pain with walking Swelling in legs Heart racing Psychiatric No Yes Anxiety Depression Gastrointestinal No Yes Trouble sleeping Abdominal pain Blood in stools Change in stools Constipation Diarrhea Heartburn Loss of appetite Nausea Vomiting 3 P a g e

Review of Systems- WOMEN ONLY Please check a box below for every question that applies to your current health General No Yes Urinary No Yes Psychiatric No Yes Chills Painful urination Anxiety Fatigue Blood in urine Depression Fever Excessive urination Trouble sleeping Night sweats Increased frequency Tired Unable to hold urine Weight gain Trouble emptying bladder Metabolic No Yes Weight loss Cold intolerance Heat intolerance Always thirsty Head/Neck No Yes Reproductive No Yes Always hungry Ear drainage Abnormal pap smear Ear pain Painful periods Eye discharge Painful intercourse Musculoskeletal No Yes Eye pain Hot flashes Back pain Hearing loss Irregular periods Joint pain Nasal drainage Vaginal discharge Joint swelling Sinus pressure Muscle weakness Sore throat Neck pain Visual changes Skin No Yes Brittle hair Brittle nails Blood/lymph No Yes Respiratory No Yes Hair loss Easy bleeding Chronic cough Excessive hair growth Easy bruising Recent cough Hives Enlarged lymph nodes Known TB exposure Itching Shortness of breath Mole changes Wheezing Rash Immunity No Yes Skin lesion Contact allergy Environmental allergy Heart No Yes Food allergy Chest pains Neurological No Yes Seasonal allergy Leg pain with walking Dizziness Swelling in legs Heart racing Numbness in arms/legs Weakness in arms/legs Trouble walking Headache Gastrointestinal No Yes Memory loss Abdominal pain Blood in stools Change in stools Constipation Diarrhea Heartburn Loss of appetite Nausea Vomiting Seizures Tremors 4 P a g e

Past Medical History Place check all that apply to you Allergies Cancer (type) Headache, migraine Kidney disease Anemia Stroke Heart disease Seizures Chest pains COPD Heart valve disorder Stroke Anxiety Depression Hepatitis C Thyroid disease Arthritis Diabetes High blood pressure Asthma Elevated lipids Irritable bowel disease Atrial fibrillation Gallbladder disease Myocardial infarction Blood clots Heartburn/ reflux Osteoporosis Past Surgical History Place the Year (if known) to all that apply to you Year Year Men Only Year Women Only Year Heart Balloon Prostate Biopsy Breast Implants Appendix Removal Gastric Bypass Prostate Surgery Tubal Knee Scope Hernia Repair Vasectomy Breast Biopsy Back Surgery Hip Replacement C-section Blood transfusion Knee Replaced D&C Heart Bypass LASIK Eye Hysterectomy Pacemaker Myomectomy Mastectomy Carpal tunnel release ORIF Fibroid Removal Cataract Removal Thyroid Removal Breast Reduction Intestine Removal Tonsil Removal Hyst and Ovaries Colostomy Bag Vaginal Hyst 5 P a g e

Adopted/unknown Alive (age) Deceased (at what age) Attention Deficit Disorder Alcoholism Allergies Alzheimer's disease Asthma Blood disease Cancer Type of cancer Heart disease after 50 Heart disease before 50 Depression Developmental Problems Diabetes Skin problems Elevated lipids Genetic disease Hearing problems High blood pressure Irritable bowel disease Learning problems Mental illness Migraines Obesity Osteoporosis Poor circulation Kidney disease Seizures Stroke Thyroid disorder Family History Place a check mark in the box to all that apply Mother Father Sister Brother Other Other relevant family history: 6 P a g e

Social History Tobacco History: Smoking Tobacco Use Tobacco Use Usage Type: daily per day Years used Age started Age stopped Non-Smoking Tobacco Use Tobacco Use Usage per Type: Daily day Years used Age started Age stopped Cigarette #packs/cig Chewing units Cigarillo cigarillos Smokeless units Cigar cigars Snuff units Pipe pipes Have you ever tried to quit smoking? No / Yes Year quit? Cessation method? Longest period tobacco free? Relapsed? Yes / No If so, why? Alcohol History: No Yes Formerly (list year quit) Type of alcohol How frequently How much a day? When was your last drink? Caffeine History: Yes No if Yes Type? Servings Per Day Demographics: The Federal Government requires us to collect the following information. This information is part of the medical record and is subject to privacy laws. Race (must choose one): o American Indian or Alaskan Native o Asian o Black or African American o Native Hawaiian or Other Pacific Islander o White o Ethnicity (check one) Hispanic Non-Hispanic Primary Language Spoken: Country of Birth (if not US): Hand Dominance: Right Left Ambidextrous Education: Highest level of Education: Any Degree obtained: Employment: Employer: Occupation: Employment Status: If Retired, Date: 7 P a g e

Military Experience: No Yes Branch: Years served: Domestic: Current Marital Status (circle one): Single Married Widowed Divorced Previously widowed? No Yes Previously divorced? No Yes Children? No Yes # Sons # Daughters Who lives with you? Sleep Patterns: Changes in sleep patterns: No Yes Average number of hours of sleep per night: Trouble falling asleep: No Yes Difficulty staying asleep: No Yes Frequent waking episodes at night: No Yes Disrupted breathing, gasping, gagging or No Yes choking for air during sleep: Lifestyle: Activity level: Moderate Sedentary Vigorous Health club member: Now Previously Never Type of exercise: Exercise frequency: Hours/week: Hobbies/Activities: Current Diet : Animals in the home: No Yes Type Religious/Spiritual: Do you have a religious affiliation? No Yes Religion name: Home Environment/Safety: Smoke detectors in home? No Yes Carbon monoxide detectors in home? No Yes Falls in the last year? No Yes Number of falls: Pool/spa at home: No Yes Seat belt use? No Yes Recent Travel Out of state? Out of country? Known exposure to disease? 8 P a g e

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