Patient s last name: First: Middle: Birth date: / / HISTORY Reason for consulting the doctor (describe your symptoms and complaint:

Similar documents
Name: Date: 1. What is the principal reason for consulting us?

New Patient Questionnaire

Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE

Mary Maier, MD Board Certified Allergist and Immunologist 2011 NW Myhre Place, Silverdale, WA (360)

Allina Health United Lung and Sleep Clinic

Name: Date: How were you referred? Physician Other Self Referral. What problem brings you or your child to this appointment?

Telephone Number Home: Work: Cell:

Headache Follow-up Visit Form

ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR

Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician:

Medical History Form

1. Instructions: Please answer the questions as they relate to the person being evaluated. Bring this form with you to your first appointment.

9220 Haven Avenue, Suite 101 Rancho Cucamonga, CA Tel: (909) Fax: (909) ALLERGY HISTORY

Adult Allergy & Medical History

Comprehensive Allergy and Asthma Care Center. New Patient Questionnaire. Patient Name: Age: DOB: Sex: M F

1 I *********IF YOU ARE NOT ON ALLERGY SHOTS PLEASE SKIP THIS SECTION AND MOVE TO PAGE 2********* NAME: AGE: ---- ID (For Office Use Only):

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

Richmond Office 4718 National Rd. E. Richmond, IN

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

NEW PATIENT HISTORY. Patient s Name: Primary Care or Referring Physician:

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

Patient Intake Form for Allegany Ear, Nose, & Throat

New Pulmonary Patient Questionnaire. Name Age Date. General Medical History

SOUTHWEST ALLERGY AND ASTHMA CENTER, P.A. ALLERGY HISTORY FORM PATIENT S NAME BIRTHDATE APPOINTMENT DATE

PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit.

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

Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code

Address Street Address City State Zip Code. Address Street Address City State Zip Code

PATIENT INFORMATION FORM (WOMEN ONLY)

PATIENT INFORMATION. Last Name First Name Address Zip Code City State

Frequent Ear Infections Past Present Have you had pressure equalization tubes? No Yes If yes, date(s): Ear Symptoms Past Present

NEW PATIENT QUESTIONNAIRE

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

NEW PATIENT INFORMATION FORM

ALLERGY CLINIC-PATIENT QUESTIONNAIRE NAME: DOB: TODAY S DATE:

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

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

Health Questionnaire

Jeffrey M. Davidson, M.D. Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco

Amarillo Surgical Group Doctor: Date:

(Continued on next page) PATIENT HISTORY: Date of Birth. Today s Date. What are the symptom(s) that bother(s) you the most?

NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C.

RHEUMATOLOGY PATIENT HISTORY FORM

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

PATIENT HEALTH HISTORY

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

Initial Consultation

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

New Patient Questionnaire. Name DOB Date

What do you feel are your child s strengths at this time?

Rockwood Natural Medicine Clinic

BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:

725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)

Patient History Form

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

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

UnityPoint Clinic - Cardiology

Patient Name: Date / Time of Appt: at

Welcome to the UCLA Center for East- West Medicine Primary Care

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.

ALLERGY & ASTHMA SPECIALISTS, P.C.

DATE OF BIRTH: MELANOMA INTAKE

List your current allergy/asthma medications, including over-the-counter medications: Medication Dose How Often?

Medical History Form

LECOM Health Ophthalmology

MCKAY UROLOGY LINCOLNTON OFFICE PATIENT HISTORY FORM

Inner Balance Acupuncture

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

Eczema: also called atopic dermatitis; a chronic, itchy, scaly rash not due to a particular substance exposure

New Sleep Patient Questionnaire. Name Age Date. General Medical History 1. Please list any surgeries you have had and their approximate dates:

PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /

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

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

New Patient Pain Evaluation

If you have asthma or use a rescue inhaler please answer the following questions:

Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY

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

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

Symptom Review (page 1) Name Date

MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name

Creve Coeur Family Medicine, LLC

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

Wisconsin Integrative Pain Specialists

Welcome to About Women by Women

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

Allergy Clinic of Iowa Advanced Allergy Therapeutics

Medical History Form

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

PATIENT HISTORY FORM

Scottsdale Family Health

Patient History Form

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

NEW PATIENT QUESTIONNAIRE

MEDICAL HISTORY RECORD

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

Transcription:

Julie A. Wendt, MD, PLLC 21803 N. Scottsdale Rd, Ste 200 Scottsdale, AZ 85255 (480) 500-1902 PATIENT HEALTH QUESTIONNAIRE Today s date: Referring Doctor: Patient s last name: First: Middle: Birth date: / / HISTORY Reason for consulting the doctor (describe your symptoms and complaint: How long have you had this problem? How often does it occur? (times per day, week, etc.) How long does it last? (hours, days, etc.) Worse at night or day? Worse inside or outside? Circle the month(s) it is most severe: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec All Year What makes it worse? What makes it better? Have you seen an allergist before? If so, please give details: Are there places you have lived that make the symptoms better or worse? Are there rooms in your house that make your symptoms worse? Where do you work? Are your symptoms better, worse or the same at work? Do any of the following make your symptoms worse? (circle) Heat Cold Exercise Weather changes Dampness Sun Damp basements Raking leaves Barns Cutting grass Hay Drinking wine Drinking beer Eating cheese Sweating Vibration Pressure PAST MEDICAL HISTORY (if YES, please explain) Allergies NO YES: Asthma NO YES: Sinus Problems NO YES: Eczema or other Skin Rash NO YES: Cataracts or Glaucoma NO YES: Thyroid Disease NO YES: Diabetes NO YES:

Rheumatoid Arthritis, Lupus NO YES: High Blood Pressure NO YES: Rhythm Disturbance of the Heart NO YES: Other Heart Disease NO YES: Liver Disease NO YES: Kidney Disease NO YES: Blood Clotting Problems NO YES: Prostate Enlargement NO YES: Surgery NO YES: Childhood Illness (chickenpox, measles, etc.) NO YES: Are you pregnant or planning to become pregnant in the near future? NO YES: Other (describe) Last Menstrual Period Hospitalizations or Emergency Room visits within the last 3 years (when and why) Current Medications, non-prescription drugs, and supplements (please note dose, number of times taken per day and start date). For patients with hives, anaphylaxis, drug allergy and angioedema, pleases include length of time. ALLERGY HISTORY Circle the drug(s) which have caused any adverse reaction: Aspirin Nonsteroidal Anti-Inflammatory Drugs (Motrin, Advil, etc.) Nose Sprays Penicillin Sulfa Drugs Other Antibiotics Antihistamines Bronchodilators (Albuterol) Others: What were the symptoms? Foods Nuts: Peanuts Fish: Shellfish: Milk Eggs 2

Wheat Soy Other: Mold Wine, Beer Cheese, Mushrooms Damp Basements, humid days, after rain Animals Cats Dogs Horses Insect stings, bites Other: Irritants House dust, dust or powders Fumes Perfumes Smoke Vaccinations (Diphtheria, Tetanus, Pertussis, or Whooping Cough, Polio, Measles, German Measles, Mumps, Influenza, Other) Other Substances Latex Radiocontrast Dye Nickel or other metal: Poison Ivy Other: INFECTION HISTORY Circle if you have had any of the following: Blood Infection Bronchitis Pneumonia Chickenpox Shingles (zoster) Hepatitis HIV or AIDS Meningitis Sinusitis Frequent or Lengthy Ear Infections Frequent or Lengthy Upper Respiratory Tract Infections Tuberculosis or Positive Tuberculin Skin Test Abnormal Chest X-Ray Abnormal Chest CT Scan Abnormal Sinus CT Scan 3

FAMILY HISTORY Mother Father Siblings Child Other Hay Fever Other Allergies Asthma Eczema Other SOCIAL HISTORY Do you or have you ever smoked? NO YES Packs per day? How Long? When did you quit? Do you drink alcohol? NO YES How much and how often? Do you have any pets or exposure to animals? NO YES For How long? Do you have (check all that apply: Basement or garden apartment Water leak Flood damage Do you have (check all that apply): Forced air heating Radiator heating Electric heating Other heating Central air conditioning Swamp cooler Fire damage Excess mold or mildew Excess dust Carpet Hardwood floors Other flooring Humidifier De-humidifier Location (circle): Country Suburbs City Farm Other: How long have you lived in your current location? Age of home? REVIEW OF SYMPTOMS Check if any symptoms are currently or recently a problem: General Weight Change Weakness Fatigue Change in alertness Skin Rash Swelling Itching Head Heart Headache Eye itching Runny nose Hoarseness Palpitations Leg swelling Dizziness Eye redness Post nasal drip Sore Throat Skipped or irregular beats Loss of smell Tearing Nose bleeds Bad breath Chest or leg pain during exertion Change in pigment or texture Sinus/facial pain or pressure Eye swelling Nasal congestion Change in gums Beating too fast or too slow 4

Lungs GI GU M/S Cough Change in sputum color Heartburn Vomiting Change in urination Joint pain Dry eyes Wheeze Coughing up blood Reflux Diarrhea Blood in urine Stiffness Dry mouth Tightness Shortness of breath, if yes (circle) at rest, with exercise, when asleep Nausea Constipation Difficulty or pain urinating Hemat/Onc Bleeding Bruising Lumps Joint swelling Change in color of fingers in cold Neuro/Psych Depression Anxiety Sleep disturbances Endo Females Change in appetite or thirst Premenopausal Change in skin, hair or nails On birth control pills Postmenopausal Chest pain Abdominal pain Food intolerance Joint redness or heat Unexplained fever or night sweats Is there anything else you d like your doctor to know today? 5

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