DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)

Similar documents
PATIENT INFORMATION FORM (PLEASE PRINT)

New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:

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

Amarillo Surgical Group Doctor: Date:

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

New Patient Information

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

Name: Date: Street Address: Referring Physician: How long have you had your current problem?

I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.

NEW PATIENT REGISTRATION FORM

John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

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

Patient Information. Address: Street Apt. # City State Zip. Seasonal Address: (If different than above address) Address: Street Apt.

* CC* PATIENT QUESTIONNAIRE

GUPTA SPORTS & SPINE CENTER

PATIENT HISTORY FORM

Cell Phone #: Home Phone #: ** Address (prefer your forever address):

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

Providence Neurosurgery PATIENT INFORMATION SHEET

New Patient Intake Form

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

Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5

NEW PATIENT INFORMATION FORM

Retinal Consultants of San Antonio PATIENT REGISTRATION

Where is your pain located? Please use the diagram below to indicate where most of your pain is located.

Providence Medical Group

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

History Form for Exceptional Home-Based Care

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

Patient Registration Form

WELCOME TO OUR OFFICE

Name: Sex: Male Female. Date of Birth: Occupation: Is this an accident or work related injury?

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

Eastern Shore MediCann Clinic, LLC

LECOM Health Ophthalmology

Patient: First Name Middle Initial Last Name. Date of Birth SSN. Address . City State Zip Code. Home Phone ( ) Cell Phone ( )

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

BOCA RATON PODIATRY, P.A. 950 GLADES ROAD #2A BOCA RATON, FL (561) fax Patient Information

New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification

MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY

Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6

NEW PATIENT HISTORY FORM. Are you diabetic? YES NO Diabetic Physician:

Athens Rheumatology Clinic, LLC Sana Makhdumi, MD

PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.

Gender: M F Race: Caucasian African American Hispanic Other

MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History

Premier Internal Medicine of Alpharetta, PC

New Patient Pain Evaluation

PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

Initial Patient Intake Form

Date of Visit / / Date of Birth / / Age

Medical History Form

Medical History Form

GIDEON G. LEWIS, M.D.

HEALTH INFORMATION FORM

NEW PATIENT INFORMATION

LAKES INTERNAL MEDICINE

The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:

DATE OF BIRTH: MELANOMA INTAKE

Creve Coeur Family Medicine, LLC

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

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM

Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:

RHEUMATOLOGY PATIENT HISTORY FORM

HD CLINIC MEDICAL HISTORY FORM

TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX

PATIENT REGISTRATION

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

PLAS/RECON SURGERY PATIENT HEALTH HISTORY

FIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA

Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:

New Patient Specialty Intake Form Department of Surgery

SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:

NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE

Please fill out this form as completely as possible. This information will determine how we treat your pain problem.

Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?

Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:

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

Laser Vein Center Thomas Wright MD Page 1 of 4

Headache Follow-up Visit Form

Laser Vein Center Thomas Wright MD RVT Page 1 of 4

Referring Physician/Therapist. Primary Care Physician. Reason for Visit

Questionnaire for Lipedema Patients

Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)

ILLINOIS BONE AND JOINT INSTITUTE Rheumatology Medical History Form

Mercy MS Center New Patient Information

Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: Address: Relationship: Address:

Pure Health Natural Medicine

New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:

Patient Interview Form

Welcome to About Women by Women

Inner Balance Acupuncture

Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY

PATIENT REGISTRATION FORM

Patient Information. Insurance Information

Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:

DIVISION OF CARDIOLOGY

Transcription:

1275 Olentangy River Rd. Ste 120 Columbus, Ohio 43212 Telephone (614) 291-5555 Fax: (614) 291-7720 Dr. David B. Kaplansky Dr. Randall Contento PATIENT Dr. INFORMATION Garrett Kalmar FORM www.columbusohiopodiatrist.com 7509 E. Main Street Reynoldsburg, Ohio 43068 Telephone: (614) 868-5555 Fax: (614) 291-7720 DATE: / / PATIENT NAME: DATE OF BIRTH: / / AGE: SEX: M F Last First MI Home Address: SSN CITY/STATE: ZIP: HOME PHONE #: ( ) - MAY WE LEAVE A MESSAGE? YES NO ALTERNATE PHONE #: ( ) - MAY WE LEAVE A MESSAGE? YES NO E-MAIL: MAY WE LEAVE A MESSAGE? YES NO PRIMARY LANGUAGE: ETHNICITY DO YOU HAVE A LEGAL GUARDIAN OR HEALTHCARE POWER OF ATTORNEY? YES NO IF YES, NAME: RELATIONSHIP: PHONE #: ( ) - EMERGENCY CONTACT: RELATIONSHIP: PHONE #: ( ) - PRIMARY CARE DOCTOR: PHONE #: WHO (EX: NAME OF DOCTOR, FRIEND, INTERNET) REFERRED YOU TO US? PHARMACY: ZIP PHONE #: ( ) - IS THERE A FAMILY MEMBER OR OTHER PERSON YOU WOULD LIKE FOR US TO SHARE YOUR MEDICAL INFORMATION? YES NAME(S) NO WHO IS RESPONSIBLE FOR PAYMENT? RELATIONSHIP TO PATIENT? ADDRESS: CITY/STATE: ZIP: PHONE #: ( ) - INSURANCE INFORMATION PRIMARY INSURANCE COMPANY NAME ADDRESS: CITY/STATE: ZIP: PHONE #: ( ) - INSURED NAME: DATE OF BIRTH EMPLOYER CONTRACT # GROUP # SECONDARY INSURANCE COMPANY NAME ADDRESS: CITY/STATE: ZIP: PHONE #: ( ) - INSURED NAME: DATE OF BIRTH EMPLOYER CONTRACT # GROUP # 1

SOCIAL HISTORY MARITAL STATUS:! SINGLE! MARRIED! PARTNERED! SEPARATED! DIVORCED! WIDOWED USE OF ALCOHOL:! NEVER! NO LONGER USE! HISTORY OF ALCOHOL ABUSE! NUMBER OF DRINKS PER WEEK - USE OF TOBACCO:! NEVER! QUIT HOW LONG AGO?! SMOKE PACKS/DAY FOR YEARS USE OF RECREATIONAL DRUGS:! NEVER! QUIT HOW LONG AGO? TYPE EMPLOYER: OCCUPATION: HOW MUCH ARE YOU ON YOUR FEET AT WORK?! 10%! 25%! 50%! 75%! 100% DO OTHERS DEPEND UPON YOU FOR THEIR CARE?! CHILDREN AGE! ELDERLY OR DISABLED FAMILY MEMBER! OTHER EXERCISE:! NEVER! RARE! OCCASIONAL! WEEKLY! SEVERAL TIMES A WEEK! DAILY TYPES OF EXERCISE: HEIGHT FEET INCHES WEIGHT POUNDS SHOE SIZE FAMILY HISTORY DO YOU HAVE A FAMILY HISTORY OF: FAMILY MEMBER (EXAMPLE: MOTHER, FATHER, SISTER)! DIABETES! CANCER! HEART DISEASE! HIGH BLOOD PRESSURE! STROKE! RHEUMATOID ARTHRITIS! OTHER PLEASE LIST ALL PRIOR SURGERIES: TYPE OF SURGERY DATE 2

PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS): NAME DOSE REASON? YOUR MEDICAL HISTORY ALLERGIES:! NONE KNOWN! MEDICATIONS (LIST BELOW)! ANESTHESIA! FOODS! TAPE! LATEX! SHELLFISH! IODINE! OTHER Medical Problems: Which of the following conditions are you currently being treated or have been treated for in the past (please check) Heart disease / Murmur / Angina Shortness of breathe Eye disorder / Glaucoma Diabetes High cholesterol Asthma Seizures Kidney / Bladder problems High blood pressure Lung problems / cough/ COPD Stroke Liver problems / Hepatitis Low blood pressure Sinus problems Headaches / Migraines Arthritis (rheumatoid or osteoarthritis) Heartburn (reflux) Seasonal allergies Neurological problems Cancer Anemia or blood problems Tonsillitis Depression / Anxiety Ulcers/colitis Hepatitis Swollen ankles Ear problems Psychiatric care Thyroid problems Infectious Disease (HIV, AID s) Others/any additional information regarding your medical conditions 3

Review of Systems: circle or write in any symptoms that apply to you currently Constitutional: (nausea, recent illness, fever, chills, night sweats, anorexia, fatigue, insomnia, weight gain/loss) Eyes (visual changes, cataract, glaucoma, discharge, injuries, glasses or contacts) Head, Ears, Nose, Throat (head injuries, headache, dizziness, difficulty with hearing, pain, discharge, ear infections, ventilation tubes, sinus congestion, sore throat, discharge: watery or purulent, difficulty in breathing through nose, bloody nose, sore throat or tongue, difficulty in swallowing, dental defects, swollen glands, masses) Lungs(shortness of breath, ability to keep up with peers, cough, heezing) Heart (cyanosis, arrhythmia, edema, heart murmurs or "heart trouble," pain over heart), Gastrointestinal (nausea, vomiting, abnormal bowel movements, abdominal pain, jaundice, reflux) Genitourinary (dysuria, hematuria, urethral or vaginal discharge, sores, pain, venereal disease, pregnant, abortions) Musculoskeletal ( back pain, stiffness, swelling, muscle weakness, deformities, difficulty in moving extremities or in walking, joint pains and swelling, muscle pains or cramps) Skin (skin cancer, rashes, calluses, nail changes, psoriasis, cellulitis, skin color change, abnormal moles, easy bruising or bleeding) Neurologic (headaches, fainting, dizziness, seizures, numbness, tremors) Psychiatric (nervousness/anxiety, drug use or abuse, psycosis, suicidality) Endocrine: Hypo/Hyper-thyroid, hyperglycemic/diabetes CURRENT PROBLEM (CHIEF COMPLAINT) WHAT SPECIFIC PROBLEM BRINGS YOU TO OUR OFFICE TODAY? WHERE IS THE PAIN/PROBLEM LOCATED? PLEASE MARK ON THE PICTURES BELOW. LEFT FOOT RIGHT FOOT TOP BOTTOM BOTTOM BOTTOM OF TOP INSIDE OUTSIDE INSIDE OUTSIDE HOW LONG AGO DID THIS PROBLEM FIRST START? DAYS / WEEKS / MONTHS / YEARS 4

DID YOUR PAIN OR PROBLEM:! BEGIN ALL OF A SUDDEN! GRADUALLY DEVELOP OVER TIME HOW WOULD YOU DESCRIBE YOUR PAIN?! NO PAIN! SHARP! DULL! ACHING! BURNING! RADIATING! ITCHING! STABBING! OTHER HOW WOULD YOU DESCRIBE YOUR PAIN? (PLEASE CIRCLE) NO PAIN MILD PAIN MODERATE PAIN SEVERE PAIN SINCE THE TIME YOUR PAIN OR PROBLEM BEGAN, HAS IT:! STAYED THE SAME! BECOME WORSE! IMPROVED WHAT MAKES YOUR PAIN OR PROBLEM FEEL WORSE?! WALKING! STANDING! DAILY ACTIVITIES! RESTING! DRESS SHOES! HIGH HEELS! FLAT SHOES! ANY CLOSED TOE SHOE! RUNNING! OTHER WHAT MAKES YOUR PAIN OR PROBLEM FEEL BETTER? WHAT TREATMENTS HAVE YOU HAD FOR THIS PROBLEM? HOW HAS THIS PROBLEM AFFECTED YOUR LIFESTYLE OR ABILITY TO WORK? WAS THIS PROBLEM CAUSED BY AN INJURY?! YES (DESCRIBE BELOW)! NO TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL STATUS. DATE SIGN NAME OF PATIENT, PARENT OR GUARDIAN REVIEWED BY UPDATED 4-2016 5

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