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Transcription:

Pharmacy Name/Location/Phone number: Family Physician Name: Phone: Address: Referring Physician Name: Phone: Address: First Emergency Contact: Relationship: Home/cell phone: Work phone: Second Emergency Contact: Relationship: Home/cell phone: Work phone: Personal Designation form on file (/N): If yes, name of person designated: Patient s Occupation: Employer: Full-time or Part-time: Patient s email address: Active MyUPMC account (/N):

Insurance information Primary Insurance: Group: ID: Copayment: Secondary Insurance: Group: ID: Copayment: If applicable: Auto: Workers compensation: Date of Injury: Claim #: Insurance Name (auto or workers compensation): Address: Contact agent and phone number: Attorney name and phone number: Attorney Address:

Medications (include over the counter medications, vitamins and supplements) Medication Name Dosage Allergies (drug, food, or environmental) Allergic reaction to: Reaction Allergic to: Reaction Allergic to: Reaction Shellfish Iodine Latex MRI contrast (dye) CT contrast (dye) IVP contrast (dye) Angiogram contrast (dye)

Reason for today s visit: Patient reported: Height: ft in Weight: lbs Review of Systems (please put x in all that apply) I have no current symptoms: Fever Shortness of Breath Joint Pain Seizures Weight Gain Wheezing Joint Swelling Dizziness Weight Loss Chronic Cough Falls Lightheadedness Malaise/Fatigue Bloody Sputum Leg/Arm Pain Leg/Arm Weakness Night Sweats Neck Pain Numbness/Tingling Weakness Chest Pain Lower Back Pain Speech Difficulty Decreased Appetite Leg Cramping Thoracic Pain Disturbances in Coordination Leg Swelling Difficulty Walking Headaches Muscle Cramps Confusion Hearing Loss Difficulty Swallowing Disorientation Tinnitus Nausea Rash Facial Spasm Throat Pain Abdominal Pain Skin Lesion Facial Numbness Ear Pain Blood in Stool Mole Change Facial Weakness Loose Teeth Bowel Incontinence Loss of Balance Facial Pain Lumps in Neck Loss of Smell Bladder Incontinence Lumps in Groin Loss of Taste Blindness Urgency Easily Bruises/Bleeds Blurred Vision Frequency Depression Double Vision Impotence Frequent Infections Nervous/Anxious Eye Pain Pain when Urinating Environmental Allergies Memory Loss Loss of Vision Urinary Burning Cold Intolerance Nipple Discharge Difficulty Urinating Heat Intolerance Loss of Menstrual Cycle Excessive Thirst Other symptoms:

Past Medical History (please put x in all that apply) Aneurysm Disease Spondylosis (arthritis) Kidney Disease Cranial Tumor Stroke or TIA Liver/Hepatitis Disease Dementia Blood Disease Lung Disease Disc Disease Cancer Pancreatitis Head Trauma Diabetes Peptic Ulcer Disease Migraine Headaches DVT Psychiatric/Behavioral Problems Non-migraine Headaches Gallbladder/Biliary Disease Pulmonary Embolism Paralytic Syndrome Heart Disease Rheumatoid Arthritis Parkinson's Disease High Blood Pressure Superficial Disease Seizures HIV/AIDS Thyroid Disease Spinal Tumor High Cholesterol Other Past Medical History: Surgical History (please put x in all that apply) Adverse Reaction to Anesthesia Craniotomy DBS Placement Endarterectomy Intrathecal Pump Spinal Cord Stimulator Brain Radiation Ventricular Shunt VNS Placement Thyroid Surgery Pituitary Surgery CABG (heart surgery) Coronary Artery Stent Cervical Spine Surgery Thoracic Spinal Surgery Lumbar Surgery Epilepsy Surgery Stereotactic Radiosurgery Microvascular Decompression Trigeminal Neuralgia Surgery Appendectomy Tonsillectomy/Adenoidectomy Hysterectomy Cholecystectomy (gallbladder removal) Prostate Surgery Fracture Surgery Other Surgical History:

Family Medical History (please put x in all that apply) Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Sisters Brothers Other Unknown/None Adverse Reaction to Anesthesia Aneurysm Asthma Bleeding Disorder Brain Tumor Cancer, Other Dementia Diabetes Heart Disease Hypertension Mental Illness Migraine Parkinson's Disease Peptic Ulcer Disease Seizures Stroke Tuberculosis Vascular Malformations

Social History Smoking Tobacco Use: Never a smoker Former Smoker Current Every Day Smoker Heavy Tobacco Smoker Passive Smoke Exposure Current Some Day Smoker Light Tobacco Smoker Packs/Day: Start date: End date: Type: Cigarettes Pipe Cigars Ready to quit: or N Smokeless Tobacco: Never used Former user Current user Number of years: Start date Quit date: Ready to quit: or N Alcohol Use: or N Number of drinks per week: Glasses of wine Shots of liquor Cans of Beer Drinks containing 0.5 oz of alcohol Drug Use: or N Use per week: Type of drug:

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