Department of Neurology New Patient Form
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1 Department of Neurology New Patient Form FIRST NAME: LAST NAME: DATE OF BIRTH: PRIMARY CARE PROVIDER & CLINIC: PREVIOUS NEUROLOGIST: I. REASON FOR VISIT - CHIEF COMPLAINT (HISTORY OF PRESENT ILLNESS) Please describe the concern or problem that brings you in today: Is this visit related to worker s compensation? (circle one) Is this visit related to any legal actions? (circle one) If this problem is the result of an accident, when did the accident occur? Do you have any questions for your doctor? II. PAIN ASSESSMENT Do you experience pain as part of your daily life? (circle one) If yes, please describe the location(s), onset, duration, and characteristics of your pain: If yes, on a scale of 1 to 10 (0 = no pain, 10 = the worst pain), how would you rate your pain? 1 of 5 Please complete all pages
2 III. HISTORY OF FALLS Have you had any significant falls in the past 6 months? If yes, please explain: IV. HANDEDNESS Are you (circle one): Left Handed Right Handed V. FAMILY HISTORY Do you have a family member affected with: Condition Brain Tumor Seizures or epilepsy Dementia Parkinson s Multiple Sclerosis Thyroid Disease Type/affected relative Condition Muscle Disease Neuropathy Other Neurological Disorder Hypertension Diabetes Migraines Type/affected relative Write other conditions: VI. MEDICATION HISTORY Please list all MEDICATIONS you take routinely, prescribed or over-the-counter, along with the dosages: (If you are a Portland Clinic patient and our list is up to date leave blank) Medication: Dose: Frequency: Please list all allergies and sensitivities (e.g. medications, foods, latex, iodine, etc.) 2 of 5 Please complete all pages
3 VII. PAST MEDICAL HISTORY: Have you had or do you have any of the following conditions? Alcoholism High Blood Pressure Arthritis Headache Asthma Hepatitis Cancer Heart Attack Chest Pain Jaundice Colitis Kidney Disease Depression / Anxiety Other Heart Disease Diabetes Pain (Chronic) Drug Addiction Rheumatic Fever Emphysema Stomach Ulcers Frequent Kidney Infections Thyroid Disease Frequent Bladder Infections Trouble Sleeping Gallbladder disease Suicidal Thoughts Gout Other VIII. SURGERIES: (List procedure and approximate year) Procedure Year Procedure Year 3 of 5 Please complete all pages
4 IX. PERSONAL HABITS: Do you drink alcohol? If yes: Regularly Socially Hard liquor 1-3 oz per day over 3 oz per day Beer 1 bottle/can per day 2 bottles/cans per day 3 or more bottles/cans per day Wine 1-2 glasses per day 3-5 glasses per day more than 5 glasses per day Do you consume more than 5 drinks within a 24 hour period? How many days in the last 6 months did you consume more than 5 drinks in a 24 hour period? Do you smoke? Have you smoked in the past? Do you or have you used recreational / illicit drugs? If yes, what have you used? When did you last use above substance? Do you drink caffeinated drinks? If yes, list how many per day of the following: Coffee; Tea; Soda; Energy Drinks X. CURRENT SYMPTOMS IN THE LAST 6 MONTHS: (please mark all that apply) 1. Head, Eyes, Ears, se, Throat, Lymph des: Headaches Deafness Double vision Hoarseness of voice Tinnitus (buzzing or humming) Photophobia (light bothers eyes) Swollen and/or painful lymph nodes Head trauma Neck swelling Pain and/or drainage from ears Nasal and/or sinus congestion Visual loss or change se bleeds Neck stiffness Sneezing Sore throat Glaucoma Teethe grinding / clenching Headaches Hearing problems Vision problems Dental problems Sinus problems Current Symptoms Continued on Next Page >> 4 of 5 Please complete all pages
5 2. Respiratory System: Shortness of breath Sputum/secretion production Wheezing 3. Cardiovascular System: Chest pain, discomfort, heaviness, tightness Shortness of breath with exertion PND (waking up short of breath) 4. Gastrointestinal System: Anorexia (poor appetite) Nausea and/or vomiting Constipation or diarrhea Weight loss or gain 5. Genitourinary System: Hematuria Oliguria (infrequent urination) Incontinence Heavy menstrual flow Polyuria (urination of large volumes of urnie) 6. Nervous system: Weakness/paralysis one side of body Urinary and/or fecal incontinence (wet or soil underwear) Memory loss, sleep disturbance, mood disorders (anxiety, depression) 7. Musculoskeletal System: Joint pain / swelling / redness Muscle aches and pains Back pain 8. Dermatological System: Rash Mole changes Pigmentation (change in color) Breast pain Cough Hemoptysis Breathing difficulty Orthopnea (sleeping on two or more pillows) Leg swelling High blood pressure Hematochezia (red blood in bowel movements) Melena (black bowel movements) Jaundice Abdominal pain cturia (urination at night) Frequency (frequent urination) Pyuria (cloudy urine) Urgency (sensation to urinate) Sexual dysfunction Insomnia Snoring Daytime sleepiness Sleep apnea Neck pain Leg / foot cramps Leg restlessness Pruritus (itching) Breast lumps Bleeding or bruising Changes in nipples Palpitations Chest pain Heartburn Dysphagia (difficulty swollowing) Stomach pain Weight change: loss lbs, gain lbs Symptoms of menopause Irregular periods PMS Bladder problems Excessive urination or thirst Seizures / shaking Numbness Loss of consciousness Dizziness Weakness Breast lumps / discharge Allergic reaction Change in skin / hair 5 of 5 Please complete all pages
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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
Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S
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:
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
Chemotherapy Side Effects Worksheet
Page 1 of 6 Chemotherapy Side Effects Worksheet Medicines or drugs that destroy cancer cells are called cancer chemotherapy. It is sometimes the first choice for treating many cancers. Chemotherapy differs
HEARING & BALANCE QUESTIONNAIRE
HEARING & BALANCE QUESTIONNAIRE Name Age Date of Birth Date I. DIZZINESS: The following questions refer to your dizziness. If you are not experiencing dizziness, please skip to the next section. Please
LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty
Welcome to Active Care Atlanta
Welcome to Active Care Atlanta Name Birth Date Age Male Female Cell # Home # Work # Address City, State & Zip Email Occupation Employer Social Security # - - Marital Status Single Married Divorce Other
Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
CONSULTATION & CONSENT FORMS p. 1 of 5 C J HERBAL REMEDIES, INC. ********************************************************************************
CONSULTATION & CONSENT FORMS p. 1 of 5 ******************************************************************************** List your full name, age, sex, and today's date List your complete address List your