Jeri Shuster, M.D., P.A.

Similar documents
NEW PATIENT HISTORY. Primary Care Physician Preferred Pharmacy Pharmacy address Phone. Reason for today s visit. Pregnancies abortions miscarriages

Patient Health Forms

NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.)

Adult Health History

IN CASE OF AN EMERGENCY NOT LIVING WITH YOU

University Gynecologic Oncology Associates

Medical History Form

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

Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:

New Patient History. Patient Name: Date of Birth: Reason for Today s Visit: Today s Date: Who is your Primary Care Physician (PCP)?

Patient Name Date of Birth Age. Other phone ( ) . Other

Medical History Form

NEW PATIENT QUESTIONNAIRE

Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: May we leave a

Name: Date of Birth: Age: Address: City State Zip

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

New Patient History Form (Age 18 and over)

Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX

Health Questionnaire

Name Appointment Date. Age Date of Birth Date Completed

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

Pure Health Natural Medicine

Adult Health History for NEW Patients

Adult Health History for New Patient

Medication Allergies

Adult Health History New Patient

Questionnaire for Women

PATIENT HISTORY FORM

Female Patient Questionnaire & History

Saint Louis University Center for Endometriosis Questionnaire PRE-OPERATIVE. Patient Name: Date of Birth: / /

New Patient Questionnaire. Name DOB Date

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

Urogynecology New Patient Form

RESEARCH PARTICIPANT REGISTRATION FORM

HORMONE BALANCE QUESTIONNAIRE FOR WOMEN

Patient History Form

Heart Murmur Chest Pain Palpitations Swelling of feet Shortness of breath

16 East 40 th St, 2 nd Fl, New York, NY Ph fax

Welcome to About Women by Women

Patient History Form

Patient History Form

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

Ginger N. Cathey, MD Urogynecology 7900 Fannin, Suite 4000 Houston, TX 77054

Female Patient Questionnaire & History

Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio

Name: Today s Date: Address: State, Zip Code

New Patient Intake Form

Patient Information. Name: Date of Birth: Age: (Last) (First) (M.I.) Home Address: City: State: Zip Code: Home Phone: Cell Phone: Address:

Who is filling out this intake form? Self Spouse Parent Guardian

Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).

THE OB/GYN CENTRE NEW PATIENT HISTORY

Health History. Personal Health History. Institute of Complementary Medicine. FOC Health History - ICM

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

New Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( )

INSURANCE DISCLAIMER

Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

Adult Health History for NEW Patients

Creve Coeur Family Medicine, LLC

GIDEON G. LEWIS, M.D.

ANY FAMILY HISTORY OF ANEURYSM OR DVT?

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

Please describe, in detail, when the symptoms began:

Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.

SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE

New Patient Medical History Form

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443)

DATE OF BIRTH: MELANOMA INTAKE

ALLERGIES. If yes, please list the food and non-medication (i.e. latex) allergies and type of reaction you had: MEDICATIONS

Southern Maine Integrative Health Center Adult Intake Form

Personal Data. Present Symptoms

Lehigh Valley Physician Group

Name MR# Date Name of your primary care physician: Name of your OB/GYN physician:

Ayurvedic Intake Form

Health History Questionnaire. Age Date of Birth Gender. Married Single Separated Divorced Widowed Partnership

FAMILY MEDICINE New Patient Medical History Form

PRIMARY CARE (719)

Name Age Est Weight Height. In brief, why are you seeing the doctor today? List your allergies: List your medications, including dosages:

Patient Name: Date of Birth:

Patient Information. Insurance Information

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

1405 NE Douglas Lee s Summit, MO Phone: Date: Fax: Female Information and Health Summary

Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT

Female New Patient Package

MEDICAL QUESTIONNAIRE

G E R A L D A. F E U E R, M D

New Patient Medical History

Hormone Consultation for Women

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

Christine Chai, M.D. 901 Dover Drive, Suite 214 Newport Beach, CA 92660

Patient Information: Date: Last Name: Street Address: City: SS #: First Name: Sex: M F Birthdate: Contact Information:

Breast implants Breast reduction surgery Breast biopsy Breast lumpectomy Chest reconstruction Other:

Integrative Consult Patient Background Form

MGH Beacon Hill Primary Care New Patient Form

Evolve180 / Ideal Northwest Health Profile

Transcription:

Please help us to help you by completing this health history form. We will review together at your first visit. Included is potentially relevant Ob-Gyn, Medical, Surgical, and pertinent family history. Name: Reason for today s visit: OB HISTORY: Number of full term pregnancies: Number of premature deliveries: Number of miscarriages or terminations: Number of live births: Dates of vaginal deliveries: Dates of caesarean deliveries: GYN HISTORY: First day of last menstrual period: Month: Day: Year: Age at first menstrual period: Age at last menstrual period (age at menopause): Number of days from start of one period to start of next period (e.g. 28 days): Range of menstrual periods (e.g. cycles occur every 3 weeks to every 6 months): Duration of flow (count from start of spotting until all bleeding/spotting ends: e.g. 7 days): Date of last PAP smear: Month: Day: Year: PAP result: normal / abnormal Do you have history of testing positive for cervical dysplasia, pre-cancer, cancer, CIN, SIL? Have you had colposcopy (looking at cervix with magnifying microscope): Y / N Do you have a history of HPV? Y / N Y / N Date of last mammogram: Month: Day: Year: Mammogram result: normal / abnormal Other breast imaging within last 1 2 years: ultrasound / MRI / result: Date of last DXA bone density scan: Month: Day: Year: Result: Normal / osteopenia (low bone mass) / osteoporosis

Current method of birth control: abstinence / female partner /sub-fertility / condom / diaphragm / oral contraceptive pill / NUVA Ring / Depo Provera / IUD / female sterilization / vasectomy / menopause / other: Menstrual problem: heavy menses (saturating 1 pad/hr for at least 4 hrs or heavy enough to disrupt normal activities of daily living) / prolonged menses (> 7 days duration) / anemia due to menses / D&C / endometrial biopsy / hysteroscopy / endometrial ablation /menses less than every 3 months / menstrual cramps / premenstrual cramps / PMS / fibroids Have you been diagnosed with: endometriosis / chronic pelvic pain / pelvic congestion syndrome / uterine fibroids / bicornuate uterus /ovarian cyst / ovarian tumor / vulvodynia (chronic vulva burning or itching) Do you have a history of infections? yeast / bacterial vaginosis / trichomonas / pelvic inflammatory disease (PID) / bladder infection / kidney infection / HPV (human papilloma virus) / genital warts / herpes / chlamydia / gonorrhea / HIV AIDS / syphilis Have you had HPV vaccine (Gardasil / Cervarix): Y / N Breast problems: cyst / fibrocystic / lump / nipple discharge / pain / needle aspiration / biopsy / pre-cancer / cancer in situ (DCIS) / invasive cancer. If positive for any, please circle Left / Right / Both. Menopause problems: hot flashes / night sweats / sleep difficulty / fatigue / cognitive or memory difficulty / vaginal dryness / painful intercourse Bladder problems: urinary frequency / urgency / loss of urine when experiencing urge to void / loss of urine with cough or sneeze / bladder infection / bladder infection after intercourse / kidney stone SEXUALITY: Age at onset of sexual activity: Sexual orientation: heterosexual / lesbian / other: Number of lifetime sexual partners: Approximate date of most recent sexual activity: Length of time in current sexual relationship: years / months Painful sex / low libido / orgasm difficulty/ abuse Have you ever been diagnosed with cancer: breast / ovary / fallopian tube / uterus / cervix / vagina / vulva / colon / rectum Family history of cancer: breast / ovary / fallopian tube / colon / pancreas / brain / genetic cancer risk Family history of deep blood clots of legs / pulmonary embolism / heart disease prior to age 50 / osteoporosis / hip fracture in parent

PAST MEDICAL HISTORY: Please help us to help you by checking all that apply: Acne Alcohol 3 or more/day Anemia Anorexia nervosa Anesthesia problems Anxiety Arthritis Asthma Auto-immune condition Barrett s esophagus Blood disorder Blood clot (deep) Blood clot (superficial) Blood transfusion Bulimia Breast condition Cancer Cholesterol Chronic pain Colon polyp Date(s) of colonoscopy(ies): Colonoscopy result: normal / polyp / other: Follow up advised: 1 yr / 5 yrs / 10 yrs / other: Connective tissue disorder COPD Depression Diabetes Type 1 Diabetes type 2 Disability (please note accommodations that you require) Diverticulosis Diverticulitis Emphysema ENT condition Endocrine condition Eye disorder Fibromyalgia Foot condition Fracture Fracture from standing height Gall bladder disease Gastrointestinal GERD Genetic mutation carrier Irritable bowel syndrome (IBS) Hair loss Hair growth (hirsutism) Hearing impairment Headache Heart attack Heart disease Heart murmur requiring antibiotic prior to dental work Hyperparathyroid (overactive parathyroid gland) Hypertension (high blood pressure) Hyperthyroid (overactive thyroid, weight loss) Hypothyroid (underactive thyroid, weight gain)

Infectious disease Pulmonary embolism Psychiatric illness Joint replacement surgery Rheumatoid arthritis Kidney disease Kidney stone Seasonal allergies Seizure disorder Lupus Skin condition Steroid medication Melanoma for > 3 consecutive months Musculoskeletal condition Substance abuse Migraine with aura Migraine without aura Tobacco use Thyroid nodules Thyroid condition Neurological disease Ulcer Obesity Osteoarthritis Vitamin D deficiency Osteopenia Varicose veins Osteoporosis PLEASE LIST ALL SURGICAL PROCEDURES. Please indicate whether procedure was Left side vs Right side. (If hysterectomy, please indicate whether surgery was laparoscopic, abdominal, vaginal or robotic. Please indicate whether ovary(ies) removed during surgery.) Date: Procedure: Date: Procedure: Date: Procedure: Date: Procedure: Date: Procedure:

SOCIAL HISTORY: Marital status: Married / Single / Widowed / Divorced / Separated / Domestic Partner Occupation: Highest level of education you have completed: high school / 2 yr College / 4 yr college / postgraduate / other: Exercise: number of hours / week: Smoking status: never smoker / former smoker / current every day smoker / current some day smoker / unknown if ever smoked Alcohol: # of drinks in average week. Street drugs: No / Yes: _ Prescription medications (please include dosage): Over-the-counter medications: (please include aspirin, vitamins, herbal supplements). MEDICATION ALLERGIES: Name of medication (please include dosage): _ Reaction: anaphylaxis / shortness of breath / swelling / hives / rash / itching / nausea / vomiting / other: Name of medication (please include dosage): _ Reaction: anaphylaxis / shortness of breath / swelling / hives / rash / itching / nausea / vomiting / other: Name of medication (please include dosage): _ Reaction: anaphylaxis / shortness of breath / swelling / hives / rash / itching / nausea / vomiting / other: Name of medication (please include dosage): _ Reaction: anaphylaxis / shortness of breath / swelling / hives / rash / itching / nausea / vomiting / other: Are you allergic to peanuts? Yes / No Reaction: anaphylaxis / shortness of breath / swelling / hives / rash / itching / nausea / vomiting / other:

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