Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL Phone (727) FAX (727)

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1 Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL Phone (727) FAX (727) Enclosed are a series of questions that are designed to give us the best possible background of your previous health and the things that are bothering you at this time. Please take the time to answer the questions to the best of your ability. Write carefully as this will be a part of your permanent record If you do not understand a question, put a question (?) next to it Please complete and bring with you at your scheduled appointment time Please also bring you insurance cards and referral if applicable WE REQUIRE 48 HOURS CANCELLATION NOTICE OR YOU MAY NOT BE ABLE TO BE RESCHEDULED Scheduled Appointment Date Time Name Home Number Work Number Cell Number Address City/State Zip Code Social Security # Age Birth Date Occupation (For Access to Patient Portal) Spouse s Date of Birth Spouse s Name Other members of household and relationship to you Next of Kin Phone Please be sure to bring your insurance cards and driver s license with you to your appointment. Please provide your insurance information so that we can file your claims to your insurance company properly. Primary Insurance Name Plan and/or Group # Subscriber s name Secondary Ins Name Plan and/or Group # Subscriber s name Identification Number Pt/subscriber relationship Subscriber s Date of Birth If you have a secondary insurance please complete below Identification Number Pt/subscriber relationship Subscriber s Date of Birth Write family / referring physician details below: Name: Address: Phone #: Fax#: 1 Updated 11/17/2014

2 Last examination by a doctor Last Chest X-Ray Last Eye Exam Last Electrocardiogram Last Mammogram Last Flu Vaccine Last Colonoscopy Last Bone Density Exam Last Tetanus Last Pneumovax Who referred you to us? PRESENT PROBLEM My present problem or complaint is as follows: (Please explain fully; this is the reason you came to The Endocrine Center of Florida, LLC) When did it start? What will relieve it? What medication have you taken for it? What do you think is wrong with you? What operations, if, any, have you had? Please list all dates of operations and surgeons name. If you so not know the exact details, please put down as much as you do remember Please list all hospitalizations (other than those listed above) including reason for admission, hospital and date, if possible

3 PREVIOUS OR PAST HISTORY ALLERGIES Please Provide Us With A Complete List of Your Medication Allergies in The Space Provided: What are the present MEDICATIONS you are taking, if any, what strength and how often do you take them? (include vitamins, tonics, over-the-counter pain and sleeping pills, and antacids) If you have any questions about what you are taking, bring all medications with you High Blood Pressure Heart Trouble Heart Attack Rheumatic Fever Anemia Stroke Cancer Venereal Disease Colitis- Diverticulosis Peptic Ulcer Hiatal Hernia Epilepsy Head Injury Pneumonia Nephrolithiasis (Kidney Stones) Other: (please explain) Please list all prior ILLNESSES: Chronic Bronchitis Emphysema Asthma Tuberculosis Positive TB Skin Test Osteoporosis Diabetes Thyroid Problem Metabolic Syndrome Phlebitis Hepatitis Gallbladder Trouble Bladder Infections Elevated Cholesterol Arthritis / Gout Early/Late Sexual Maturation/Adolescent Development 3

4 GYNECOLOGICAL AND OBSTETRICAL (if applicable) Do you menstruate (have periods)? How many days apart? At what age did you begin to menstruate? Do you have pain with periods? Yes No At what age do you think you had your last period or menopause? Have you had any bleeding of any kind since menopause? Yes No When was your last pelvic/internal exam? How many children do you have? How many times have you miscarried? Do you leak urine on coughing or sneezing? FAMILY HISTORY Illness Y Whom Illness Y Whom High Blood Pressure Tuberculosis Heart Trouble Kidney Disease Strokes Epilepsy Emphysema Bleeding Disorders Diabetes Cancer (type?) Gout Thyroid Endocrine Disorders Disorder of Sexual Maturation Mother Father Brothers Age Alive Deceased Age At Death Cause of Death Sisters Children Personal History Where were you born? Marital Status: S M W Sep D Briefly, Where have you lived at different times during your life? Do you smoke? Yes No How much? Number of years? Did you ever smoke? Yes No How much? Number of years? Do you drink alcoholic beverages? Yes No How much? Did you drink alcoholic beverages a lot in the past? Yes No How much? What exercise do you get regularly? Worked as What hobbies and interests do you have? List names and addresses of previous doctors: 4

5 REVIEW OF SYSTEMS Any problems with the following: (please check yes or no) General Y N Nervous System Y N Mouth Y N Recent fever Depression dentures Undue tiredness Nervousness Sore Throat Unexplained weight loss Trouble Sleeping Swallowing Difficulty Unexplained weight gain Excessive worry Hoarseness Head Ever under psychiatrist s care Excessive bleeding after Tense or frequent headaches Skin dental extraction Fainting spells Rashes Other Hair changes Lumps Exposure to x-rays Convulsions Easy Bruising Exposure to active TB Eyes Heart Exposure to asbestos Glasses Pain on exertion Exposure to paint fumes Discharge Shortness of breath Exposure to toxins Pain On exertion If so, what kind? Blurred Vision at rest Ears Glaucoma More than one pillow Hearing Loss Cataracts Swelling of ankles Ringing Neck Heart palpitations Discharge Goiter High blood pressure Pain Thyroid Trouble Heart murmur Gastrointestinal Stiffness Genitourinary Loss of appetite Breasts Pain/ burning on urination Indigestion Lumps Frequency Heartburn Discharge Blood in urine Nausea Extremities Trouble starting urination Vomiting Joint pain or swelling Up at night to urinate Vomiting blood Varicose veins How many times? Diarrhea Paralysis Leakage of urine Constipation Weakness Pain or trouble with sexual Blood in stools Numbness intercourse Black stools Pain on walking Chest White stools Back problems Cough Abdominal pain Which joints hurt the most? Phlegm Food intolerances Pain What foods? Blood Wheezing Nose Asthma Drainage Pneumonia Bleeding History of TB ADVANCE DIRECTIVES Do you have ADVANCE DIRECTIVES in place? If yes, please bring copies for your individual chart: DNR LIVING WILL ORGAN DONOR POWER OF ATTORNEY 5

6 DIABETES HISTORY When were you diagnosed? Age Date What were your symptoms at the time of diagnosis? (Please put a check where appropriate) Weight gain Unusual hunger Thirst Ketoacidosis Weight loss Spilling sugar Frequent urination Hypersmolar coma Weakness Skin infections Nausea Drowsiness Blurred vision Vomiting Since the time of diagnosis, were you noted to have: (Please put a check where appropriate) Eye disease Elevated cholesterol Protein in urine Nerve fiber damage Hypertension Elevated triglycerides Thyroid disease Gout Endocrine disease Retinopathy Stroke Heart disease Kidney damage Weight at the time of diagnosis: Highest weight since then Do you test your blood sugar? Yes No If yes, bring record of readings to your appointment Which glucose meter do you use? How often do you test? Have you been instructed (by a physician, nurse or dietician) in: (Please put a check where appropriate) Diabetes Daily foot exam Diet Diabetic complications Insulin Home glucose monitoring Urine testing What is your present treatment for diabetes? Diet: Calories Number of meals Number of Snacks Oral hypoglycemic agents: (name, dose and frequency) Insulin: (indicate type, exact dose and frequency Concerning your family, do you have relatives with diabetes? (indicate relationship to you, their age at diagnosis, and how they are treated for diabetes) Women: Have you ever been pregnant Yes No Did you have diabetes during pregnancy Yes No Weight of you children at birth: Are you planning / considering any future pregnancies Yes No dlh 2/17/14 6