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

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Transcription:

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure Alzheimer s Disease Deep Vein Thrombosis Cerebral Aneurysm Heart Attack Peripheral Neuropathy Heart Murmur Seizure Disorder High Blood Pressure Stroke High Cholesterol TIA Irregular Heartbeat (Atrial Fibrillation) URINARY PROBLEMS LUNG PROBLEMS Kidney Infection (pyelonephritis) Asthma Kidney Stones Chronic Obstructive Pulmonary Disease Prostate Enlargement Emphysema Urinary Tract Infection Pneumonia Pulmonary Embolism BLOOD DISORDERS Anemia GASTROINTESTINAL PROBLEMS Bleeding Disorder Cirrhosis Blood Transfusion Gastric Ulcer HIV Positive Gastroesophageal Reflux Disease Hepatitis CANCER Type: ENDOCRINE PROBLEMS Type: Diabetes, Type I (Juvenile Onset) Diabetes, Type II (Adult Onset) ANESTHESIA Thyroid Disorder: Type: Have you ever had a reaction to anesthesia? Yes No MUSCULOSKELETAL Please Describe: Osteoarthritis Osteoporosis PAST SURGICAL HISTORY : (Please list all previous surgeries) 1. 2. 3. 4. 5. 6. 7. 8. Date of Surgery Procedure Performed Surgeon s Name 1

Patient Name: Date of Birth: MEDICATION LIST Please include all prescription, over-the counter, and herbal medications you are taking. If additional space is required, please attach your medication list to this form. Medications Dosage Quantity Times Taken Per Day Date Started Date Stopped 1

Patient Name: Date of Birth: DRUG ALLERGIES AND REACTIONS: Drug Name Allergic Reaction Are you allergic to latex? Circle One: YES NO FAMILY MEDICAL HISTORY (Please list any medical conditions in your family) Relationship to Patient Living/Deceased Age Medical Conditions Mother Father Grandmother Grandfather Brother Sister Child SOCIAL HISTORY (Have you ever used the following?) Tobacco Use Circle One: Never Current Former Alcohol Use Circle One: Never Current Former Recreational Drug Use Circle One: Never Current Former Regular Exercise: Circle one: YES NO How Often? 3

Patient Name: Date of Birth: DIALYSIS INFORMATION: (If applicable) Type: Circle One: HEMO-DIALYSIS PERITONEAL (PD) Days: Circle One: Mon Tue Wed Thu Fri Sat Dialysis Center: Address: City: State: Zip: Telephone Number: Fax Number: Nephrologist: Patient Name: Date of Birth: 4

Patient Name: Date of Birth: REVIEW OF SYSTEMS (ROS): To be completed by patient ARE YOU EXPERIENCING ANY OF THE FOLLOWING? PLEASE CIRCLE Y FOR YES AND N FOR NO CONSTITUTIONAL RESPIRATORY MUSCULOSKELETAL Weight Gain Y N Wheeze Y N Muscle Pain Y N Weight Loss Y N Cough Y N Joint Pain Y N Fever Y N Bloody Sputum Y N Joint Swelling Y N Chills Y N Other Y N Weakness Y N Fatigue Y N Poor Balance Y N Loss of Appetite Y N Other Y N Night Sweats Y N GASTROINTESTINAL Other Y N Abdominal Pain Y N Nausea Y N ENDOCRINE Vomiting Y N Excessive Sweating Y N EYES Diarrhea Y N Excessive Thirst Y N Pain Y N Constipation Y N Excessive Heat Y N Discharge Y N Heartburn Y N Excessive Cold Y N Light Sensitivity Y N Blood in Stool Y N Other Y N Blurred Vision Y N Other Y N Double Vision Y N Other Y N PSYCHIATRIC GENITOURINARY Anxiety Y N Frequency Y N Depression Y N EAR, NOSE, THROAT Incontinence Y N Stress Y N Sore Throat Y N Flank Pain Y N Other Y N Hoarseness Y N Blood in Urine Y N Ringing in Ears Y N Other Y N Nose Bleeds Y N HEME-LYMPH Hearing Loss Y N Easy Bruising Y N Other Y N INTEGUMENT Swollen Glands Y N Rash Y N Excessive Bleeding Y N Moles Y N Other Y N BREASTS Sores Y N Breast Discharge Y N Breast Discharge Y N Other Y N Other: Y N ALLERGIC-IMMUNOLOGIC Sinus Allergy Symptoms Y N Frequent Illnesses Y N CARVIOVASCULAR NEUROLOGICAL Chest Pain Y N Headaches Y N Height: Palpitations Y N Confusion Y N Calf Pain Y N Dizziness Y N Weight: Leg Pain Y N Memory Loss Y N Shortness of Breath Y N Seizure Y N Other Y N Other Y N Reviewed and discussed with patient. Physician Signature: Date Reviewed: 5

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