Room # Critical Care & Pulmonary Consultants, P.C.

Similar documents
*521634* Sleep History Questionnaire. Name of primary care doctor:

1960 FP CENTER FOR SLEEP DISORDERS

WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS

New Patient Sleep Intake

Baptist Health Floyd 1850 State Street New Albany, IN Sleep Disorders Center Lung & Sleep Specialists. Date of Birth: Age:

Sleep History Questionnaire

PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE

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

Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address

Sleep Center New Patient Questionnaire

Allina Health United Lung and Sleep Clinic

Annapolis Asthma, Pulmonary & Sleep Specialists

MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE. Name: Date of Birth: / / Age: Sex: Address: City: Zip:

EMORY SLEEP CENTER Sleep and Health Questionnaire

Patient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )

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

DESERT CENTER FOR ALLERGY AND CHEST DISEASES HEALTH QUESTIONAIRE NAME. PAST MEDICAL PROBLEMS- Check mark if you have any of the following

Creve Coeur Family Medicine, LLC

PULMONARY & CRITICAL CARE CONSULTANTS OF AUSTIN 1305 West 34 th Street, Suite 400, Austin, TX Phone: Fax:

PATIENT SLEEP QUESTIONNAIRE

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

Sleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118

Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305

SLEEP HISTORY QUESTIONNAIRE

PEDIATRIC HISTORY FORM

NEW PATIENT QUESTIONNAIRE

Sleep History Questionnaire B/P / Pulse: Neck Circum Wgt: Pulse Ox

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

Premier Internal Medicine of Alpharetta, PC

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

Patient Medical History

Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:

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

Associated Neurological Specialties and Sleep Disorder Center

Sleep Medicine Questionnaire

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

Sleep Questionnaire Name: Sex: Age: Da te: Da te of birth: Height: Weight: Neck siz e: Ref erring Physician: Primary Car e MD:

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

PEDIATRIC SLEEP EVALUATION

PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely

Sleep Disorders Questionnaire

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

YOUR NAME AGE DATE. Comments. Describe your sleep problem and how long you ve had it

GARY POLK, M.D. PATIENT QUESTIONNAIRE - PLEASE PRINT

SLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:

Medical History Questionnaire

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

Sleep History Questionnaire. Sleep Disorders Center Duke University Medical Center. General Information. Age: Sex: F M (select one)

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

UnityPoint Clinic - Cardiology

Please answer as many ques ons as you can before your ini al visit to EvergreenHealth Sleep Services.

PATIENT HISTORY FORM

Amarillo Surgical Group Doctor: Date:

Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX Phone (903) Fax (903)

PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:

THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk PATIENT QUESTIONNAIRE

Patient Questionnaire

Patient Adult Information History

PATIENT DEMOGRAPHICS

NEW PATIENT HEALTH HISTORY

TIM MOORING, M.D. PATIENT QUESTIONNAIRE - PLEASE PRINT

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

ALLERGIES (food,latex,other)

130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History

Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine

Occupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Marital status: Single Married Divorced Widowed

PATIENTS DEMOGRAPHICS

Patient History Form

REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL

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

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

RHEUMATOLOGY PATIENT HISTORY FORM

Medical History Form

Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire

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

Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.

PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio

Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment:

Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy

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

Pre-Test Questionnaire. Name: Sex: Age: Date of Birth: Height: ft. in. Weight: lbs Gain? Loss? of lbs over

Wellness Visit Assessment

New Patient Questionnaire. Name DOB Date

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

ANNUAL FOLLOW-UP QUESTIONNAIRE

Sleep Symptoms & History

WELCOME TO OUR OFFICE

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

* CC* PATIENT QUESTIONNAIRE

Tallahassee Memorial Sleep Center Patient Questionnaire

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

Height: Weight: Neck Size: Does your work involve shift work? Yes No. Where did you hear about us: Physician Media Friend Other

ANY FAMILY HISTORY OF ANEURYSM OR DVT?

GoPrivateMD General Information & History

Please complete this questionnaire before your appointment.

New Patient Questionnaire

Transcription:

Room # Critical Care & Pulmonary Consultants, P.C. Health History You have been scheduled for an appointment with Critical Care and Pulmonary Consultants, P.C. This health history will help us facilitate your evaluation and allow you to think about the answers to questions that you will be asked during your visit. Please fully complete this health history and bring it to your appointment. Thank you for your cooperation! Patient Name: Date of Birth: Appointment date: Appointment time: Physician: How were you referred to our pulmonary practice? Reason for Visit Briefly describe the reason for your visit and what you hope to accomplish: Have you had a Pneumovax Vaccine? ( ) Yes ( ) No Have you had a Prevnar 13 Vaccine? ( ) Yes ( ) No Have you had a Flu Vaccine? ( ) Yes ( ) No Past Medical History (Please mark All that apply) Diagnosis Month/Year Onset Diagnosis Month/Year Onset Asthma Bronchitis Emphysema COPD Hay Fever Sinus Disease Pneumonia Interstitial Lung Disease Pulmonary Fibrosis Hives (urticaria) Tuberculosis or + PPD test Atypical Mycobacterial dis. Bronchiectasis Chronic Cough Heart Attack High Blood Pressure Chest Pain Angina Heart Murmur Congenital Heart Disease Abnormal EKG Diabetes Stroke Cancer/type Blood Clots Pulmonary Embolism Deep Vein Thrombosis Bleeding disorder Liver Disease Hepatitis Kidney Disease Sleep Apnea Insomnia Heartburn/GERD Trauma

Congestive Heart Failure Have you ever been hospitalized? YES NO If so, for what reason? Admission Date Diagnosis/Problem Length of Stay Comments Family History Alive & Deceased? Well If so, at what age? Cause of Death: Health Problems: Mother Father Please list and surgeries you have had and the approximate date of the surgery. Admission Date Type of Surgery Comments Drug allergies / Adverse Drug Reactions if None please Check Here Name of Medication Reaction Comment Are you allergic to EGGS? Yes No Do Not Know Are you allergic to IODINE? Yes No Do Not Know Are you allergic to CONTRAST DYE? Yes No Do Not Know YES NO DO NOT KNOW Have you ever had skin testing or allergy shots?

Medications Please list your current oral and inhaled medications including medication name, dose, and number of times per day you take the medication, and mark whether you take it "regularly" or only "as needed," Please list any "over the counter" medications Medication (Oral and Inhaled) Tablet strength or # puffs # of Times per Day Regular Use Only as needed Comments Do you use oxygen? (If Yes, please mark All that apply) Time of Day Date Started Liters/minute Comments Sleep Activity Continuous Social History Marital Status: Single Divorced Separated Widowed Occupation Any history of toxin or chemical exposure related to current or former occupation or hobbies? Yes No If so, please describe Smoking History Personal Habits Never smoker Do you drink alcohol? Yes No Current or Former smoker If so, what type and how much? Age started Age stopped Ever used illicit drug? Yes No Average # packs per day If so, when and what substance? Current # packs per day Tobacco Products Type Amount

List any pets you may have: Have any of your pets died recently? List all of your job experiences from earliest to current List any exposures to what you think might be a toxic substance(s) List any hobbies you may have List any places you may have traveled in the past two years List any time you have spent in the military Exercise activity Do you have an advanced care directive or surrogate care provider? No. If Yes, please describe below. Current or Recent Symptoms: Gastrointestinal: ( ) Indigestion Constitution: ( ) Night sweats or fevers ( ) Diarrhea or constipation ( ) Chills ( ) Choking ( ) Abnormal sweating ( ) Abdominal pain ( ) Weight loss/gain ( ) Difficulty swallowing ( ) Blood in stools Eyes: ( ) Visual difficulty Genitourinary: ( ) Increased urinary frequency at night ENTM: ( ) Nasal congestion or blockage ( ) Difficulty urinating ( ) Nose bleeds ( ) Ear pain/infections Musculoskeletal: ( ) Joint Pain ( ) Mouth sores Skin: ( ) Pain or color change of hands with cold exposure Respiratory: ( ) Shortness of breath ( ) Swelling in legs/feet ( ) Shortness of breath at night ( ) Skin rash ( ) Wheezing ( ) Shortness of breath around animals Neurological: ( ) Tremors ( ) Coughing up blood ( ) New weakness or numbness ( ) Cough ( ) Headaches ( ) Phlegm production ( ) Shortness of breath that is worse at work Endocrine: ( ) Infertility/impotence ( ) Sexual problems Cardiovascular: ( ) Chest pain ( ) Heart palpitations Heme/Lymp ( ) Bruising/Bleeding ( ) Loss of consciousness or passing out ( ) New Swollen Lymph Node ( ) Irregular heart beat ( ) Pain in legs with walking Psychological: ( ) Depression

Sleep History Yes No Snore loudly Stop breathing during sleep Choking or gasping during sleep Wake refreshed Wake with headaches Driving accidents or near accidents due to sleeping Tired or fatigued during usual daytime activities Kicking or twitching during sleep Restless, tingling, or crawling feeling in legs Trouble falling asleep (for how long? ) Trouble returning to sleep (for how long? ) Weak feeling in arms or legs when emotional Inability to move (paralysis) on waking How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation Sitting and reading Watching TV Sitting inactive in a public place (e.g. a theater or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in the traffic Chance for Dozing I have reviewed: Date:

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