Allan Warshowsky MD,FACOG, ABIHM. New Patient Questionnaire Date of appointment :

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Transcription:

New Patient Questionnaire Date of appointment : Name: Address: Apt# City: State: Zip: Phone: Cell: Email: Age: DOB: Referred By: Your occupation: Allergies: To Medications: Other: Reason for Today s Visit: Level of Education:

With whom are your closest relationships? Allan Warshowsky MD,FACOG, ABIHM What gives you most joy in your life? What stresses you out most in life? "What symptoms do you notice when you are stressed?" FAMILY HISTORY: MOM DAD SIBLINGS CHILDREN PARTNER Alive / Deceased current age / age at death health problems / cause of death

REVIEW OF SYMPTOMS: ( check and describe all that apply ) General Appetite (increased, decreased): Weight issues: Energy level (when are you most energized? When exhausted?) More or less exhausted after exercise? Easy bruising? Sleep (cannot get to sleep, awakens and cannot fall back asleep): Bedtime: Awaken for the day: Nighttime snack? What? Time? Night sweats (hot flashes):

Food cravings Allan Warshowsky MD,FACOG, ABIHM When during menstrual cycle? Skin /Hair/Nails (dry, oily, thinning, etc.): Head, Ears, Eyes, Nose, Throat Headache (migraine? Tension? When in menstrual cycle?): Vision, hearing problems: Sinus problems? (chronic): Sore throats? (chronic): Nose Bleeds: Trouble with taste / smell:

Cardiovascular Blood pressure: Palpitations (heart skipping beats): Blood clots or thromboses (in arms or legs): Fainting (or light-headed when changing position) Varicose veins: Chest pains: Swelling (arms or legs): Respiratory Cough: Frequent infections: Asthma: Gastrointestinal Bowel movements (diarrhea/ constipation, how many per day, per week?) Indigestion: Stomach pain: Reflux:

Bloating (relationship to eating, foods that make it worse): Hemorrhoids: Nausea: Rectal pain/ itching/ bleeding: Genitourinary Pain (pelvis, bladder): Wake to urinate (# of times/night): Blood in urine: Sexually transmitted disease: Frequent urination: Cannot hold urine: Other difficulties urinating: History of bedwetting as a child: Musculo-skeletal Where, when do you have pain? Stiffness?

Emotions- Allan Warshowsky MD,FACOG, ABIHM Balanced: Anxiety: Depression: Bad temper: Easily stressed: Memory loss: GYNECOLOGIC HISTORY (women only): Last pap: Last mammogram: Last bone density: Abnormal paps? Normal? Results? Pregnancies Full term: Vaginal delivery Cesarean Miscarriages: Terminations of pregnancy: Premenstrual symptoms When do they go away? Last period (date): Age at first period: Description of periods (Regular?):

Cycle length? No. of days? Amount of flow (heavy- moderate-light): When heaviest, how often do you change pads, tampons? Pain with the period? Abnormal bleeding? Sexually active? Birth control (if applicable) Sexually transmitted diseases: Breast problems: For Men Only Recent change in strength Difficulty with erections Lack of interest in sex Lack of focus in work

OTHER MEDICAL CONDITIONS Surgeries Allan Warshowsky MD,FACOG, ABIHM Procedure Date Supplements and Medications Personal habits Smoking: Current: Past: Alcohol (Number of drinks per day, per week): Soft drinks (Number of drinks per day, per week): Caffeine (per day, per week):

Water (glasses per day): Exercise (How often, what type): Allan Warshowsky MD,FACOG, ABIHM Sleep (How many hours per night): Energy level (Scale of 1-10, 10 being the best): Dental Care How often do you have a dental cleaning: When was the last time you had a dental cleaning: Do you floss your teeth and if so, how often: Do your gums bleed when brushing or flossing? What would you like to accomplish with this visit? Note: Please read and sign the following page. We would appreciate it if you would please honor our request in item #2. If you have labs and/or reports, you can send then only if they are within the last 6 months to a year. Thank you

NEW PATIENTS: PLEASE READ THE FOLLOWING: 1. Please fax this questionnaire to our office at 914-967-1624 at least 2 days before your appointment. Or you can email it to priscillaew@gmail.com but not to Dr. Warshowsky. PLEASE SCAN AS ONE DOCUMENT, NOT 11 SEPARATE PAGES PLEASE DO NOT TAKE A PHOTO OF EACH PAGE AS IT MUST BE FAXED OR EMAILED. 2. You will have a follow up appointment about 2-3 weeks after the first one to review all the bloodwork, and there is a charge for this appointment. 3. CANCELLATION POLICY: There will be a charge of $300 for a new patient appointment if it is cancelled fewer than 3 business days before; weekends and holidays do not count as business days. There will be a charge of $180 for regular appointments if cancelled fewer than 24 hours on a business day. 4. If you have recent labs or reports that you would like to send with your questionnaire, you may do so but not to exceed 25 pages. 5. Insurance: If you are not sure if your insurance pays for bloodwork done at an out of network physician s office, please call them before you come. 6. Our staff and many of our patients have chemical sensitivities. Please refrain from wearing perfume, cologne, or other scents when you come to our office. 7. Payment: We accept Visa, Mastercard, check or cash for payment. We do not accept American Express or Discover. Thank you for understanding our office policies. Signature Date

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