NEW PATIENT QUESTIONNAIRE

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Transcription:

NEW PATIENT QUESTIONNAIRE Last Name: First Name: Date Form Completed: Referring Physician: Address: City: Sex: Marital Status: Race: Age: Married Caucasian Single Male Divorced African American Hispanic Middle Initial: State: Zip: Female Separated Widowed Other Local Pharmacy: Phone: Mail Order Pharmacy: Fax: Employer: Occupation: Retired? Yes / No What is the reason for your visit? Please leave blank: TSPA New Patient Questionnaire - Revised 05/2011 Page 1 of 6 Phys Initial :

YOUR PERSONAL PAST MEDICAL HISTORY Please check the following symptoms and/or conditions that pertain to your past medical history: Anemia Angina Anxiety / Depression Arrhythmias Asthma BiPAP Bronchitis Cancer Cerebral Artery Disease Clotting/Bleeding Disorder Congestive Heart Failure COPD Coronary Artery Disease CPAP Cystic Fibrosis Day Time Sleepiness Diabetes Mellitus Emphysema Heart Attack Hepatitis High Blood Pressure High Cholesterol Histocytosis HIV/AIDS Insomnia Irritable Bowel Syndrome Kidney Disease Liver Dysfunction Obstructive Sleep Apnea Peptic Ulcer Disease Pneumonia Reflux Rheumatoid Arthritis Sarcoidosis Seizures Sinusitis Stroke Systemic Lupus Thyroid Disease Tuberculosis Vascular Disease Weakness Wegener s Disease Other PAST SURGERIES Year Procedure TSPA New Patient Questionnaire - Revised 05/2011 Page 2 of 6 Phys Initial :

MEDICATIONS Please list all medications that you are currently taking, including vitamins, supplemental herbs, and overthe counter medications. Medication Dosage Frequency Example: Zantac 150 mg. Twice per day ALLERGIES Medications: (Please specify medication allergy and type of reaction) Seasonal/Environmental Allergies: Other: TSPA New Patient Questionnaire - Revised 05/2011 Page 3 of 6 Phys Initial :

SOCIAL HISTORY CIGARETTE SMOKING HISTORY Never Smoked I smoked an average of packs per day starting at age and [ last smoked at age ] or [ continue to smoke]. During this time frame, the most I smoked was packs per day and the least I smoked was packs per day. The longest I quit was for years months. {transcribe: avg, range, start, end,# yrs, p-yrs, other} Smoked Other Tobacco Products OCCUPATIONAL EXPOSURE HISTORY Asbestos Exposure Other Occupational Exposures (circle those that apply) o Inorganic dusts: quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter, silica, coal dust, other ( ) o Organic dusts: farming, building inspection, woodworking, remodeling, handling vegetable matter, animals, other ( ) EDUCATION Through Grade Completed High School Completed College Post Graduate ALCOHOL HISTORY Never Drink Alcohol Occasional Drink Drinks Socially Heavy Drinker Reformed Drinker Drinks Alcohol Regularly ( # Drinks Per Day) RECREATIONAL DRUG USE Please specify drug(s): Previous Current Inhaled Injected VACCINATION HISTORY Pneumonia Vaccine (last received ) Flu Vaccine (last received ) TSPA New Patient Questionnaire - Revised 05/2011 Page 4 of 6 Phys Initial :

REVIEW OF SYSTEMS Please indicate whether you have recently, previously or never experienced any of the following symptoms: General Change in Weight Eczema Loss of Appetite Chills Fatigue Fever Night Sweats Sweats Lungs and Chest Coughing Coughing Blood Coughing Mucous Oxygen Use Shortness of Breath Wheezing Stomach and Bowel Abdominal Pain Bloody/Dark Stools Heartburn/Indigestion Nausea Trouble Swallowing Vomiting Vomiting Blood Ears, Note, Throat Cold Symptoms Hearing Difficulty Hoarseness Nasal Problems Sinus Problems Sore Throat Sleep Excessive Sleepiness Insomnia Snoring Stop Breathing Night Trouble Falling Asleep Trouble Staying Asleep Now Prior Never Now Prior Never Heart/Blood Vessels Black Out Spells Chest Pain Fast or Irregular Pulse Leg or Ankle Swelling Leg Pain with Walking Palpitations Awaken Out of Breath Nerves and Brain Arm or Leg Weakness Dizziness/Fainting Frequent Headaches Numbness/Tingling Stroke/Paralysis Blood/Lymph Nodes Enlarged Lymph Nodes Excess Bruising/Bleeding History of Blood Clot Muscle/Bones/Joint Aches Arthritis Back Pain Chest Wall Pain Joint Stiffness Joint Swelling Mental Illness Alcohol Addiction Anxiety Bipolar Depression Substance Addiction Schizophrenia Endocrine Excessive Thirst Excessive Urination Intolerance to Heat/Cold Thyroid Problems TSPA New Patient Questionnaire - Revised 05/2011 Page 5 of 6 Phys Initial :

FAMILY HISTORY Please check the following conditions that pertain to your family history: Mother: Alive (current age ) or Deceased (at age ) Mother s Medical Problems: Father: Alive (current age ) or Deceased (at age ) Father s Medical Problems: Siblings: # Alive # Deceased Sibling s Medical Problems: Children: # Alive # Deceased Childrens Medical Problems: Other Pertinent Family History if applicable: PHYSICIAN VERIFICATION I have personally reviewed the New Patient Questionnaire for this patient. Physician s Signature: Date: TSPA New Patient Questionnaire - Revised 05/2011 Page 6 of 6 Phys Initial :

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