Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX 75460 Phone (903) 905-4609 Fax (903) 905-4611 Enclosed are forms for you to complete prior to your appointment. Please bring these completed forms with you at your first visit. These forms ask for information that we need to collect at your visit. By completing them and bringing them with you, we will be able to go over them much more quickly, thereby leaving more time for the doctor to examine you and discuss other important aspects of your care during the limited time allocated for your consultation. Please try to arrive at least 15 minutes before the time you are scheduled to see the doctor as the nurse would need to gather some information prior to your seeing the doctor. If you are coming for care of your diabetes, please bring your blood sugar machine and your handwritten blood sugar logs to every visit. If you are coming for care of your thyroid problem, we will need results of thyroid ultrasounds, thyroid biopsies and other types of thyroid scans done within the past 3 years. Tests older than 3 years are also welcome if easily available. If you do not have those results yourself, please ask your doctor to send copies to us. If you have had a thyroid ultrasound, we prefer to have the actual ultrasound films to look at ourselves, if available. Some radiology departments are able to provide you with these films stored on a CD upon request. There is information about the most common thyroid problems on our web page that can be downloaded and read as pdf files. If you are coming for a thyroid problem, we encourage you to download and read any of the documents that pertain to your problem before your visit. http://parishealthcaregroup.com/endocrinology.html Thank you for choosing to come to us for help with your health. We look forward to seeing you at your visit.
Page 1 of 8 QUESTIONS FOR DIABETICS Only those coming for diabetes need to answer questions on the first 2 pages Approximately when were you diagnosed with diabetes (which year)? Please list all the pills and injections you are currently taking for your diabetes, including insulin. Medication Dose How many times a day Approx when started If on an insulin pump, approximately when did you start using the insulin pump? Please list all the different types of medications you remember having been on in the past for your diabetes (pills and injections). Medication How long on it Year Stopped Reason stopped (if known)
Page 2 of 8 Have you ever seen an endocrinologist in the past for your diabetes? When and where? Have you ever had formal diabetes education classes in the past? When and where? As far as you know, have you ever had a condition called diabetic ketoacidosis or DKA? Approximately how many times? When was the 1 st time? When was the last time? Do you regularly see an ophthalmologist (an eye doctor) for eye examinations? When was the last time you saw an ophthalmologist? Who is your ophthalmologist, if you have one? As far as you know, are there any abnormalities in your eye examinations that are specifically due to diabetes?. What is the abnormality called to the best of your recollection? As far as you know, do you have any neuropathy or nerve damage as a result of your diabetes? Do you have neuropathy due to any reason other than diabetes? Please briefly state what symtoms you have from the neuropathy. As far as you know, do you have any kidney problem, such as abnormal kidney blood test or protein showing up in your urine? What kidney problem are you aware of? THOSE COMING FOR THYROID PROBLEMS PLEASE ANSWER THE FOLLOWING SET OF QUESTIONS Approximately when were diagnosed with your current thyroid problem? Have you ever seen an endocrinologist for your thyroid? When and where? Have you ever had thyroid surgery in the past? If you have had thyroid surgery in the past, when was it and what was the surgery for?
Page 3 of 8 Have you ever had radioactive iodine treatment for a thyroid problem? If you have had radioactive iodine in the past, when and where was it and what was it for? As far as you are aware, have you had a thyroid ultrasound in the past? When and where? As far as you are aware, have you had any other type of thyroid problems in the past? When and what was it (if you know)? What, if any, medications are you currently taking for thyroid problems? EVERYONE The rest of the questions are for everyone. FAMILY HISTORY Relative Age if alive Age at death if deceased Any Medical Problems Mother Father Are there any other relatives with histories of diabetes, thyroid disease, heart disease, elevated cholesterol or triglycerides, or other hormonal disorders that you are aware of? Please provide some details about which relatives and what they have
Page 4 of 8 Please list all other medications you are currently taking apart from those already listed above Medication Dose and how many times a day/week Medication Dose and how many times a day/week Have you used tobacco? If yes, what? For how long (years)? If cigarettes, how many packs or how many cigarettes do (did) you smoke per day? If you have quit, when did you quit? Do you drink alcohol?. If yes, amount and type of alcohol drank each week: Have you used recreational drugs (marijuana, heroin, crack etc)? If yes, what? Has your weight changed in the past year? If yes, how much gained? lbs. or Lost lbs. Reason for weight gain or weight loss if known What is the most you have ever weighed (not pregnancy related? lbs. What is the least you have ever weighed as an adult? lbs. Do you get exercise or do heavy work each week? If yes, approximately how many hours? Marital Status? With whom do you live now? Any children? Ages and sexes of children if any
Page 5 of 8 Highest education level you completed: GED High School College Graduate School Present job: Past Jobs: If you served in the military, give branch and years Please list any surgeries you have had below Year Surgery Year Surgery Please list any significant medical problems you have or have had (include things like high blood pressure, diabetes, heart disease, asthma, stomach ulcer, acid reflux, sleep apnea, depression or anxiety, stroke etc) Medical Problem Year if known Medical Problem Year if known
Page 6 of 8 Please list any hospital admissions you have had in the past Year Reason for admission Year Reason for admission REVIEW OF THE SYSTEMS (ACTIVE OR VERY RECENT PROBLEMS). CHECK YES OR NO FOR ALL LISTED. Constitutional Fever Chills Significant weight loss Significant weight gain Fatigue/tiredness EYES Dry eyes Vision change EARS, NOSE, MOUTH THROAT Difficulty hearing Frequent nose bleeds Sinus problems Sore throat Bleeding gums Dry Mouth Mouth ulcers Oral abnormalities CARDIOVASCULAR Chest pain Arm pain on exertion Shortness of breath when waking
Page 7 of 8 Shortness of breath when lying down Palpitations Known to have heart murmur RESPIRATORY Cough Wheezing Shortness of breath Coughing up blood Sleep apnea GASTROINTESTINAL Abdominal pain Nausea Vomiting Change in appetite Diarrhea Constipation Vomiting blood Blood in stools PSYCHIATRIC Depression Anxiety ENDOCRINE Fatigue Increased thirst Hair loss Abnormal or increased hair growth Feel unusually cold Feel unusually hot SKIN Rash Itching Jaundice GENITOURINARY Frequent urination Frequent urge to urinate Difficulty urinating Incontinent of urine (leakage)
Page 8 of 8 Burning or pain when urinating FEMALE ORGANS WOMEN ONLY Age began having menstrual periods: years Had hysterectomy Had both ovaries removed Had one ovary removed Had tubes tied Date last period began / / Periods occur about every weeks/days and last about days Periods are abnormally heavy Bleeding in between periods Contraceptive use MALE ORGANS MEN ONLY Prostate trouble Swelling, pain, tenderness or lump on testes Trouble with erections Had a vasectomy MUSCULOSKELETAL Muscle aches Muscle weakness Joint pain Back pain Joint swelling Swelling in the extremities NEUROLOGICAL Loss of consciousness Weakness Numbness Seizures Dizziness Headaches Thank you very much for your responses. I look forward to seeing you at your office visit Ebele Chira, MD