Name: DOB: Date: MRN#:

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Transcription:

Name: DOB: Date: MRN#: Thank you for choosing Baylor Scott & White Internal Medicine Las Colinas. We appreciate your assistance by completing this form, as it will help us better care for you. Were you referred by another physician? If so, who? Reason for visit: Allergies: List any significant reactions to food/meds Allergy Reaction No known allergies 1. 2. Medications List any medications you take, prescription and nonprescription and their dosage: No medications 1. Medication Dose Refill needed (Y/N) 2. 3. 4. 5. 6. 7. Local Pharmacy: Address: Phone Number: City: Mail order Pharmacy:

Your Care Team: Please provide the names of any other providers that you currently receive care from. Past Medical History: Please check all that apply. No medical problems Abnormal pap smear Depression Hypothyroidism Anemia GERD Kidney Stone Anxiety Gestational Diabetes Heart attack Asthma GI bleed Kidney Failure Atrial fibrillation Gout Kidney Disease Breast cancer Hepatitis A Seizures Cervical cancer Hepatitis B Skin Cancer Chicken pox Hepatitis C Stroke Chronic Back pain Hypertension Substance Abuse Colon cancer Hyperthyroidism Ulcers Deep Vein Thrombosis Additional History: Surgical History: Please Check all that apply: No surgeries Abdominal aneurysm Cerebral Aneurysm Liver Transplant Appendectomy Gall Bladder removal Lung Transplant Back Surgery Colon Surgery Mastectomy (breast removal) R/L Bariatric Surgery Heart Transplant Neck Surgery Brain Surgery Hip Surgery R/L Previous C-section Breast Biopsy R/L Hysterectomy Shoulder Surgery R/L Breast Enhancement Hysterectomy with Sinus Surgery ovaries removed Breast Surgery R/L Kidney removal R/L Tonsillectomy CABG-Heart bypass Kidney Transplant Tubal ligation (tubes tied) Cardiac Catheterization Knee arthroscopy Valve replacement Carotid Endarterectomy Knee Surgery R/L Other: Carpal Tunnel surgery R/L Cataract Surgery R/L

Family History: Please check all that apply: None Alcohol abuse Alzheimer s Asthma Autoimmune Breast cancer Cancer Colon Cancer COPD/Bronchitis Depression Diabetes Heart Disease Hyperlipidemia Hypertension Lung Cancer Melanoma Osteoporosis Ovarian Cancer Prostate Cancer Seizures Stroke Thyroid Disease Mother Father Sister Brother Daughter Son Mat GM Mat GF Pat GM Pat GF Other: Social History: Alcohol Use: Number of drinks/week: glasses of wine cans of beer shots of liquor Sexually Active: t currently Never Type of birth control: Partners: Female Male Both Drug Use: Former Type of Drugs: Tobacco Use: If so what type: Cigarettes Pipe Cigars Electronic cigarettes Snuff Chew Year Started: Packs/day: Quit Date: Occupation: Marital status: Single Married Divorced Widowed Number of children: Years of education: Who do you live with?

OB/Gyn History: Last Menstrual period: Duration of periods: Interval between periods: Heavy periods: # of pregnancies: # of miscarriages: # of abortions: Immunizations: Please enter the dates of your most recent vaccinations Tetanus/TdaP/Td: Prevnar: Zostavax /Shingles Vaccination: Human Papilloma Vaccination (HPV)/Gardasil: Pneumovax: Influenza Vaccination: Preventative Care: Please enter the dates of your most recent tests. Colonoscopy Sigmoidoscopy Hemoccult/Test for Blood in Stool Osteoporosis Test/DEXA For Women Only Pap Smear Mammogram Breast Exam For Men Only Last Prostate exam PSA Date Result Advanced Directives: Do you have a living will: Do you have a Medical Power of Attorney: Do you have an out of hospital Do Not Resuscitate (DNR): If you answered YES to any of these questions, please bring a copy of the legal document to your first visit. If you answered NO, we have information that will be provided for you to discuss with your family so that Advanced Medical Directives can be incorporated into your medical chart.

Baylor Scott White Internal Medicine Las Colinas Pt Name DOB Date: REVIEW OF SYSTEMS QUESTIONNAIRE In order to accurately assess your concerns, please CIRCLE any of the symptoms below that you have experienced in the past 2 weeks. CONSTITUTIONAL HEAD/EARS/NOSE/ THROAT EYES RESPIRATORY Activity Change Appetite Change Chills Chronic Pain Daytime Sleepiness Execessive Sweating Fatigue Fever Unexpected Wt Change Congestion Dental Problem Drooling Ear Pain Facial Swelling Hearing Loss Mouth Sores Nosebleeds Post Nasal Drip Reflux Runny Nose Sinus Pain Sinus Pressure Sneezing Snoring Trouble Swallowing Voice Change Discharge Itching Pain Redness Sensitivity to Light Visual Disturbance Gasping for air Chest Tightness Choking Cough Shortness of Breath Voice Change Wheezing CARDIOVASCULAR Chest Pain Leg Swelling Palpitations GI Abdominal Bloating Abdominal Pain Anal Bleeding Blood in Stool Bowel Incontinence Constipation Diarrhea Nausea Rectal Pain Vomiting ENDOCRINE Cold Intolerance Heat Intolerance Excessive Thirst Excessive Appetite Urinary Frequency GENITAL/URINARY MUSCULOSKELETAL SKIN Bladder Incontinence Breast Lump Decreased Libido Difficulty Urinating Pain w/intercourse Painful Urination Increased Urinary Frequency Incontin @ night Flank Pain Frequency Genital Sore Blood in Urine Menstrual Change Urination at night/# Pelvic Pain Sexual Difficulties Urgency Urine Decreased Vaginal Bleeding Vaginal Discharge Vaginal Pain Joint Pain Back Pain Trouble Walking Joint Swelling Muscle Aches Neck Pain Neck Stiffness Color Change Hair Change Hair Loss Nail Change Pallor Rash Skin Change ALLERGY Environmental Allergies Food Allergies Immunocompromised NEUROLOGICAL Dizziness Facial Asymmetry Headaches Light-headedness Numbness Seizures Speech Difficulty Passing out Tremors Weakness HEMATOLOGIC Lymph Node Swelling Bruise/Bleed Easily PSYCHIATRIC Agitation Behavior Problem Confusion Decreased Concentration Depressed Mood Sad Hallucinations Hyperactive Nervous/Anxious Self-Injury Severe Stress Sleep Disturbance Suicidal Ideas

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