Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:

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Transcription:

Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital Status: Single Married Divorced Widowed In Case of Emergency Please Contact: Relationship to Patient: Name: Phone #: Employer Information Employer Name: Employment Status: Full Time Part Time Student Retired Address: City: State: Zip Code: Work Phone Number: Patient Occupation: Insurance Information (Please provide card to Front Office) Primary Insurance Plan Name: Insured Name: Date of Birth: Social Security #: Insured Employer: Employer Phone Number: Secondary Insurance Plan Name: Insured Name: Date of Birth: Social Security Number: Insured Employer: Physician Information Name of Referring Physician: Employer Phone Number: Name of Primary Physician: How did you find our practice? Website/Internet Newspaper TV Referral (circle all that apply) Do you have a Preferred Pharmacy? Yes No If yes, please provide the following information: Name of Pharmacy: Phone Number: City: State: Zip Code: 1

Vascular Surgery Clinic Name: Date: Date of Birth: Height: Weight: MEDICATIONS (Prescription, Over the counter and Vitamins) MEDICATION DOSE FREQUENCY MEDICATION ALLERGY NE NAME OF MEDICATION REACTION NAME OF FOOD ALLERGY REACTION 2

MEDICAL HISTORY Please circle or to any past or current medical conditions Vascular Surgery Clinic Atrial Fibrillation / Arrhythmia Coronary Arterial Disease Heart Failure Dementia Seizure Disorder Diabetes Mellitus Type 2 Asthma Chronic Obstructive Pulmonary Disease/Emphysema Bleeding Disorder Anemia Deep Vein Thrombosis Pulmonary Embolism MRSA Hx High Cholesterol / Hyperlipidemia Myocardial Infarction / Heart Attack Depression Drug Abuse Hepatitis C Peptic Ulcer Disorder Chronic Kidney Disease / End Stage Renal Disease Stroke / TIA Temporary Blindness Speech Difficulty Hypertension Liver Cirrhosis Hypothyroid Obesity Obstructive Sleep Apnea 3

SURGICAL HISTORY DATE Appendectomy C-Section CABG (Coronary Bypass Graft) Cholecystectomy Hysterectomy PTCA Hx (Coronary Angioplasty) Angioplasty / Leg Stent Other Vascular Surgery Clinic Relationship Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather FAMILY HISTORY Heart Other Vascular Age of Disease Stroke Aneurysm Problems (Please Specify) Occurrence 4

Vascular Surgery Clinic SOCIAL HISTORY NEVER Do you smoke? Number of years Packs per day Interested in quitting? How long you smoked before quitting? Number of years Packs per day DAILY WINE WEEKLY BEER NEVER MONTHLY OTHER Do you consume alcohol? How often? Which alcoholic beverage? Drug abuse? LEARNING PREFERENCE What is your learning preference? (Circle all that applies) LISTENING READING DEMOSTRATION PICTURES/VIDEOS OTHER (Please Specify): FALL RISK Have you fallen in the last 30 days? (Please circle one) 5

Vascular Surgery Clinic REVIEW OF SYSTEMS Are you currently having problems with any of the following? (Y=, N=) Constitutional Symptoms: Cardiovascular Symptoms: Musculoskeletal Symptoms: Endocrine Symptoms: Y N Fever Y N Chest Pain on Exertion Y N Muscle Aches Y N Fatigue Y N Chills Y N Arm Pain on Exertion Y N Muscle Weakness Y N Cold Intolerance Y N Weight Gain ( lbs.) Y N Shortness of Breath Y N Joint Pain Y N Hair Loss Y N Weight Loss ( lbs.) Y N Heart Palpitations Y N Back Pain Y N Increased Hair Growth Y N Decreased Appetite Y N Heart Murmurs Y N Swelling in Arms/Legs Y N Irregular Menstrual Eye Symptoms: Y N Calf or Jaw Pain Y N Difficulty Walking Y N Increased Thirst Y N Change in Vision Y N Ankle Swelling Integumentary Symptoms: Hematologic/ Lymphatic: Y N Eye Pain Respiratory Symptoms: Y N Dry Skin Y N Swollen Glands Y N Eye Irritation Y N Cough Y N Jaundice Y N Bruising Ear, Nose, and Throat: Y N Wheezing Y N Rashes Y N Excessive Bleeding Y N Decreased Hearing Y N Shortness of Breath Y N Discoloration Neurologic Symptoms: Y N Vertigo Gastrointestinal Symptoms: Y N Growth/Lesions Y N Loss of Consciousness Y N Ringing in the Ears Y N Nausea Y N Ulcers Y N Slurred Speech Y N Nose/Sinus Problems Y N Vomiting Allergic/Immunologic: Y N Weakness Y N Nose Bleeds Y N Vomiting Blood Y N Runny Nose Y N Numbness Y N Sore Throat Y N Abdominal Pain Y N Sinus Pressure Y N Headaches Y N Difficulty Speaking Y N Change in Appetite Y N Itching Y N Memory Lapse Y N Bleeding Gums Y N Heartburn Y N Hives Y N Loss of Balance/Falls Y N Teeth Abnormalities Y N Black or Tarry Stool Y N Frequent Sneezing Y N Restless Legs REASON FOR VISIT TODAY (PLEASE SPECIFY) Client s Signature Date 6

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