The Endocrinology Clinic Health Questionnaire and Medical History
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- Clement Morton
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1 J. Dustin Bernard D.O. Endocrinologist 2074 Parker Street, Suite #120 San Luis Obispo, CA Phone (805) Fax (805) The Endocrinology Clinic Health Questionnaire and Medical History NAME NICK NAME DOB Why are you seeing Dr. Bernard Today? Referring Doctor? CURRENT MEDICAL PROBLEMS CURRENT MEDICATIONS (Please include hormones, birth control pills, herbal, vitamins, diet supplements, or over-the-counter medicines that you take on a regular basis. Attach a separate sheet of paper if needed.) MEDICATION DOSE FREQUENCY ALLERGIES to FOODS or DRUGS (reaction that occurs) MEDICAL HISTORY List any significant medical illness (HIGH BLOOD PRESSURE, DIABETES, THYROID PROBLEMS, CANCER, HEART PROBLEMS, etc.) or injuries (fractures, etc.) SURGICAL HISTORY OPERATION REASON DATE Page 1
2 FAMILY HISTORY Indicate any major health problems of relatives. RELATIVE AGE HEALTH PROBLEM/ CAUSE of DEATH AGE AT DEATH FATHER MOTHER BROTHER(S) SISTER(S) FATHER'S FATHER FATHER'S MOTHER MOTHER'S FATHER MOTHER'S MOTHER CHILDREN Review of Your Past Medical History Are you CURRENTLY having any of the following symptoms? Please circle or check ONLY any symptoms that you have RIGHT NOW. CONSTITUTIONAL- Fever, Chills, Weight gain/ loss, Sense of Wellbeing, or appetite, Energy loss, Sweats, Frequently ill. SKIN- Rashes, Itchy skin, Color change, New or changing moles, Lumps, Nail Changes, Hair Changes, Skin cancer HEAD- Headaches, Eye pain, Double vision, Blurry vision, Blind spots, Glaucoma, Cataracts, Laser surgery, Loss of hearing, Ringing in the ears, Bloody noses Last yearly eye exam Eyes Dilated? NOSE and THROAT- Sinus trouble, Hay fever/seasonal allergies, Hoarseness, Change in voice, Nose bleeds, Change in taste or smell, Nasal polyps, History of radiation treatment to face or neck, History of thyroid disease, Difficulty swallowing liquids or solids NECK- Swollen glands, Difficulty swallowing, Lumps, Pain in the neck region, Nodules BREAST- Pain, History of lumps, Nipple discharge Page 2
3 CARDIAC- Heart palpitations, Fast heart beat, Chest pain, History of heart murmurs, High blood pressure, Edema (swelling of legs and/or ankles), High cholesterol, Abnormal valves, Heart enlargement, History of heart attack, Heart Failure, Arrhythmia, Shortness of Breath RESPIRATORY- Cough, Wheezing, Shortness of breath: at rest, at night, with exertion, Pain associated with breathing, Asthma, Exposure to asbestos, History or tuberculosis Have you ever had a tuberculosis test? YES NO Date GASTROINTESTINAL- Nausea, Vomiting, Change in bowel habits, Diarrhea, Constipation, Trouble swallowing, Heart burn, Abdominal pain, Ulcer, Gallbladder disease, Hemorrhoids, Hepatitis, Jaundice, Rectal problems, Black or tarry stool, Colon Polyps, History of jaundice GENITOURINARY- Painful Urination, Frequency, Urgency, Urinating at night, Abnormal bleeding in urine, Kidney stones, Trouble starting or stopping urine stream, Bladder infection, Trouble controlling your bladder, Sexually transmitted diseases How many times do you urinate at night? HEMATOLOGICAL- Easy bruising, Transfusion Reactions, Excessive bleeding, Anemia MUSCULOSKELETAL- Arthritis, Gout, Joint pains, Swelling and stiffness, Muscle cramps, Back pain, Neck pain, Red or swollen joints, Osteoporosis, Loss of Height Have you ever had a scan for osteoporosis? Date PERIPHERAL VASCULAR- Varicose veins, Blood clots, Leg pain, Muscle cramps in arms or legs NEUROLOGICAL- Right or Left Handed, Frequent or severe headaches, Fainting, Loss of consciousness, Seizure or Convulsion (Epilepsy), Spinning sensation (vertigo), Balance problems, Periods of lightheadedness, Difficulty walking, Numbness or tingling in arms or legs NEUROPSYCHIATRIC- Seizures, Paralysis/paresis, Extreme mood change, Insomnia, Anxiety, Psychiatric care, Suicidal ideations, Difficulty experiencing pleasure, Emotional illness, Feelings of worthlessness or guilt ENDOCRINE- Heat/Cold intolerance, Increased thirst, Abdominal pain, High blood sugars, Thyroid problems, Reproductive problems, Weak bones, Abnormal electrolytes, Sexual problems, Difficulty concentrating, Any known gland problems ALLERGIC/IMMUNOLOGIC- Skin or other rashes, Reactions to medications or foods Page 3
4 If any of the above symptoms require additional explanation, please do so here: For Women Only: Age of first menstrual cycle Are your menstrual cycles regular? If not, explain Date of your last cycle Any pain during periods? Have you gone through menopause? At what age Surgical Natural Number of pregnancies Number of children Number of miscarriages (if any) Any sexual problems? (Lack of libido, etc.) Do you perform monthly breast exams? Date of Last Mammogram Date of Last Pap Smear Have you ever had any of the following: Abnormal Pap smear, Breast discharge, Unusual vaginal bleeding or pain, Unusual vaginal discharge? If yes, explain Have you ever taken estrogen therapy? Yes No Did your mother take DES (hormone) while pregnant with you? For Men Only: Have you ever had any prostate problems? Are you having urination at night? Are you experiencing any difficulty with erections? Do you get morning erections? Do you have a low sex drive? Have you ever had any lumps in your testicles? Are you having pain during sexual intimacy? Do you experience hot flashes? Page 4
5 SOCIAL HISTORY Marital Status (circle or check): Single, Married, Significant Other, Widowed, Divorced, None of Dr s Business With whom do you live? Birthplace Part of world you grew up in? Education Occupation Religion (optional) Leisure Activities and Hobbies HABITS Smoking/ Tobacco Use: Packs/day for # of years Year Quit Alcohol Use:, Daily Amount Do you feel this is a problem? Recreational or illicit drug Use: If yes, specify Caffeine Use: Coffee Tea Soda: # Cups Daily Do you have an advanced directive or power of attorney in place in the unlikely event of a sudden tragedy that would render you unable to make decisions? If you have any other questions or concerns for Dr. Bernard please list. Thank you for taking the time to complete this form! Signature Date If under 18 years of age please have legal guardian sign here: Version Page 5
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Review of Systems. Eye/Ear/Nose/Throat. hard to empty bladder. palpitations/irregular heartbeat. persistent cough, wheezing. feelings of depression
Name: Review of Systems DOB: / / For staff: place patient label here. Check here if no symptoms. Check concerns below only if you have experienced symptoms recently. General loss of appetite abnormal weight
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM (Please Print) Name: LAST FIRST Ml Street Address: STREET APT CITY STATE ZIP Home Phone #: ( ) ) Cell Phone #: ( ) ) Social Security #: Birth date: Age: Sex: M ; F Marital Status:
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
PRIMARY CARE ASSOCIATES MASS GENERAL WEST NEW PATIENT QUESTIONNAIRE
PRIMARY CARE ASSOCIATES MASS GENERAL WEST NEW PATIENT QUESTIONNAIRE Name: DOB: Date completed: Where have you received health care previously? Do you require a translator? Yes No Do you have any hearing,
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS:
San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet
San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your
Medical History Form
MAIN SATELLITE 49 Veronica Avenue Suite 202 901 West Main Street Suite 203 Somerset, NJ 08873 Freehold, NJ 07728 P: 732 640 5316 P: 732 640 5327 F: 800 689 2361 F: 800 689 2361 128 Rehill Avenue Suite
OrthoVirginia Registration Information 2016
OrthoVirginia Registration Information 2016 Patient Information Patient Name Account # Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex Male Female City, State
PAST MEDICAL HISTORY REVIEW OF SYSTEMS
SOUTHEASTERN SPORTS MEDICINE Page 1 of 6 21 Turtle Creek Drive Asheville, NC 28803 DATE PATIENT INFORMATION PATIENT NAME: Last First Middle ( ) Child ( ) Single ( ) Married ( ) Widow(er) ( ) Divorced Address
LIST ALL MEDICATIONS (BOTH PRESCRIBED AND OVER THE COUNTER) AND SUPPLEMENTS
PLEASE PRINT PATIENT LAST NAME: FIRST NAME DATE OF BIRTH: / / AGE: ADDRESS: APT CITY STATE ZIP HOME PHONE # CELL PHONE # WORK PHONE # SEX M F MARITAL STATUS DRIVER S LICENSE # SOCIAL SECURITY # - - EMPLOYER
Riverwalk Physical Therapy, L.L.C. ACUPUNCTURE HEALTH HISTORY QUESTIONNAIRE
Riverwalk Physical Therapy, L.L.C. ACUPUNCTURE HEALTH HISTORY QUESTIONNAIRE Name: Date: Street: City: State: Zip: Cell Phone: Home Phone: Occupation: Marital Status: Date of Birth: Age: Gender: M F Height:
SPINE PATIENT HISTORY FORM
Trenton Orthopaedic Group 116 Washington Crossing Road 1225 Whitehorse-Mercerville Road Pennington, NJ 08534 Bldg. D., Suite 220 Mercerville, NJ 08619 22-1897695 SPINE PATIENT HISTORY FORM Please print
IF THIS IS RELATED TO A WORKMAN S COMPENSATION CLAIM OR AN AUTOMOBILE ACCIDENT, PLEASE FILL OUT ADDITIONAL SHEET IN THE BACK OF THIS PACKET (PIP FORM)
PATIENT INFORMATION Last Name: First: MI: of Birth: Social Security #: - - Address: City State Zip Home#: ( ) - Cell#: ( ) - Employer: Employer#: ( ) - Occupation: Retired Unemployed Student Self-Employed
PATIENT INFORMATION INSURANCE PHONE NUMBERS ACCIDENT INFORMATION GENERAL INFORMATION. Sex: M F Age Birthdate. Date. Name. Relationship to Patient
PATIENT INFORMATION Name Address City State Zip Sex: M F Age Birthdate Single Married Significant Other Widowed Separated Divorced Patient SS# Occupation Employer Emp. Address Emp. Phone Spouse/Partner
INITIAL PATIENT QUESTIONNAIRE-
Date: Patient Address: Home Phone: Work Phone: Age: Height: cm/inches Weight: kg/lbs Male Female Referring Physician s Name: Physician Phone: Physician Address: Type of Practice (Internist, Surgeon, etc.):