Vanderbilt University Autonomic Dysfunction Center Autonomic Dysfunction Questionnaire

Similar documents
Medical History. Instructions. My telephone number is: 1 Tools Medical History

WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS

CONSULTATION ADMITTANCE FORM

Vanderbilt Autonomic Dysfunction Center Medical Questionnaire

Adult Demographics Form

Amarillo Surgical Group Doctor: Date:

PATIENT SLEEP QUESTIONNAIRE

Symptom Review (page 1) Name Date

Mary South, MD 3647 Medina Road Medina, OH Phone: Fax: has an appointment. on at AM/PM.

Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.

Women s and Men s Health Intake Form Comprehensive Physical Therapy Center

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

ACTIVE EDGE CHIROPRACTIC

UROGYNECOLOGY. In your own words, please write the nature of your medical problem for which you are being seen today.

J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health

Sleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118

Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,

Margie Petersen Breast Center

Sleep History Questionnaire

EMORY SLEEP CENTER Sleep and Health Questionnaire

**************************************************************************

Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone

PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely

Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?

The Rehabilitation Institute Cancer Rehabilitation

Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother

N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro

VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:

ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG

GUPTA SPORTS & SPINE CENTER

Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#

PAIN QUESTIONNAIRE. Patient Name: Patient Date of Birth: Appointment Date:

Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.

New Patient Information

ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:

Preferred phone: Best time to call you: Morning Afternoon Evening

PATIENT INFORMATION Please print clearly and complete all blanks

City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,

HEALTH HISTORY QUESTIONNAIRE

HEALTH INFORMATION FORM

Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form

Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire

General Questionnaire

GoPrivateMD General Information & History

WELCOME TO THE MILLER CHIROPRACTIC CLINIC

Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5

Patient Registration (Please complete all pages. Thank you.) PATIENT INFORMATION

JOHN MICHAEL ROACH, MD

Joseph S. Weiner, MD, PC Patient History Form

Name(last, first): Home Phone: Cell Phone: address: Date of birth: SSN:

Rupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?

NEW PATIENT INFORMATION

55 S. Main Street, Driggs, ID (208)

ACUPUNCTURE SPECIFIC INTAKE FORM

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

*521634* Sleep History Questionnaire. Name of primary care doctor:

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

Patient Interview Form

NEW PATIENT VISIT QUESTIONNAIRE

3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:

DIVISION OF CARDIOLOGY

Name DOB Age Date Address Phone

Emotional Relationships Social Life Sexually Recreation

Inner Balance Acupuncture

Patient Intake Form for Acupuncture Treatment at Infinite Healing

COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:

FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:

DESERT CENTER FOR ALLERGY AND CHEST DISEASES HEALTH QUESTIONAIRE NAME. PAST MEDICAL PROBLEMS- Check mark if you have any of the following

Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?

Brunswick Pulmonary and Sleep Medicine Lawrence Davanzo, DO, FCCP 49 Veronica Ave, Somerset, NJ Phone# Fax#

PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:

Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:

Cardiff Cardiac Ablation PROM (C-CAP2)

MEDICAL HISTORY RECORD

PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.

HEALTH INFORMATION FORM

CHIROPRACTIC ASSOCIATES CLINIC

Patient History. 6. Rate the severity of this problem from 0-10 /10 7. Describe previous treatment/exercises

ANY FAMILY HISTORY OF ANEURYSM OR DVT?

PLEASE DESCRIBE YOUR PRIMARY HEALTH CONCERNS

2. Have your symptoms affected your ability to carry out your daily activities? YES NO

PATIENT REGISTRATION

NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM

Psychiatric Evaluation Intake Form

ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address

AHI - New Patient Information

MEDICAL QUESTIONNAIRE (female)

New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )

Providence Medical Group

ACTG Adherence Follow Up Questionnaire

SLEEP SCREENING QUESTIONNAIRE

NeuroSolutions Initial Intake

Richard Senysyzn, MD Psychiatry for Adults 1260 River Acres Drive New Braunfels, TX , Fax. (888)

New Client Intake. First Name Last Name. Address. City State Zipcode Date of Birth. Home Phone Mobile Phone. Relationship to you Phone

Transcription:

Vanderbilt University Autonomic Dysfunction Center Autonomic Dysfunction Questionnaire Name: Date: Address: Phone number:( ) E-mail address: Birth date: / / Age: Sex: M F Height Weight Ethnic group: a. Caucasian (Non-Hispanic) b. African-American/Black (Non-Hispanic) c. Hispanic/White d. Hispanic/Black e. Asian f. Other (please specify) Are you currently working? Yes No If yes, what is your current occupation? How many days of work have you missed in the last month because of illness? If no, when did you last work? Doing what? Allergies To medication? To food? Other? 1 of 5

Have you been told that you have a disorder of the autonomic nervous system? Yes If so, by whom? What did they call this disorder? No List your medical problems (e.g., diabetes, high blood pressure, asthma, kidney disease, stroke, cancer, heart disease, etc.) Do you believe you have or have you been told that you have one of the following conditions? (circle all that apply) 1. mitral valve prolapse 2. chronic fatigue syndrome 3. fibromyalgia 4. irritable bowel syndrome 5. sick building syndrome 6. hypoglycemia 7. multiple chemical sensitivity Which of your problems is most troubling to you? What do you hope to get out of your stay at the Autonomic Dysfunction Center? When and how did your current symptoms begin? 2 of 5

Current medications Please list all of your current medications. Please include all prescription, non-prescription, and herbal preparations: Name Dose (mg) Times per day Family History Which of your mother/father/sister/brother have had: Diabetes High blood pressure Asthma Heart disease Kidney disease Stroke Cancer Other disease 3 of 5

Use the scale below to complete the list regarding your symptoms and their frequency: 1:Never 2:< 1 time 3:2-4 times 4:5-7 times 5:daily a month a month a month 1 2 3 4 5 urinary incontinence or leaking 1 2 3 4 5 constipation 1 2 3 4 5 fatigue 1 2 3 4 5 nausea 1 2 3 4 5 headache 1 2 3 4 5 heartburn 1 2 3 4 5 clamminess of skin 1 2 3 4 5 tremulousness 1 2 3 4 5 impotence (for males) 1 2 3 4 5 sensation of rapid heartbeat 1 2 3 4 5 impaired memory 1 2 3 4 5 fainting 1 2 3 4 5 itching of the feet 1 2 3 4 5 chest discomfort 1 2 3 4 5 sensation of forceful, slow heartbeat 1 2 3 4 5 dizziness 1 2 3 4 5 feeling of weakness 1 2 3 4 5 frequent wakening during the night 1 2 3 4 5 shortness of breath 1 2 3 4 5 blurring or dimming of vision 1 2 3 4 5 difficulty emptying the bladder 1 2 3 4 5 excessive daytime sleepiness 1 2 3 4 5 loose, watery stools 1 2 3 4 5 anxiety 1 2 3 4 5 muscle aches 1 2 3 4 5 bloating after meals 1 2 3 4 5 itching of the hands 1 2 3 4 5 lightheadedness (faintness) 1 2 3 4 5 difficulty falling to sleep 1 2 3 4 5 difficulty with starting to urinate 1 2 3 4 5 sensation of head or room spinning 1 2 3 4 5 excessive sweating 1 2 3 4 5 confusion 1 2 3 4 5 neck or shoulder aching 1 2 3 4 5 joint aches 1 2 3 4 5 difficulty staying asleep 4 of 5

Heart Rate and Blood Pressure Recordings Please record your blood pressure and heart rate under the following conditions on three separate occasions. Lie quietly for 10 minutes and then take blood pressure and heart rate. Then stand in one place. At the end of 3 minutes and then again at 10 minutes, take blood pressure and heart rate. Record the results below. This is VERY IMPORTANT. These records cannot be properly evaluated without this information. blood pressure heart rate How were these reading taken? a. Who measured your blood pressure and heart rate? b. Does the cuff automatically make the measurements? c. Did you use an arm cuff or finger cuff. Please return this form to: Referral Nurse Autonomic Dysfunction Service AA-3228 Medical Center North Vanderbilt University Medical Center Nashville, TN 37232-2195 Fax: (615) 343-8649 5 of 5

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback