Patient Information. Spouse s Name if a child, name of. Street Address. City State Zip Home Phone Cell Phone Work Phone
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1 Joseph Fife, O.D. Paradise Canyon Eye Care 1449 N 1400 Ste. 24 St George, UT Phone: Patient Information Date Patient s Name (please print) Spouse s Name _ if a child, name of parent or guardian Street Address City State Zip Home Phone Cell Phone Work Phone Date of Birth M or F SSN Occupation Employer Spouse s Employer If you are a new patient, how did you hear about our office? Medical History Do you have difficulties with any of the following systems? Hypertension Thyroid Cardiovascular Cancer Diabetes Cardiovascular Musculoskeletal Endocrine (Glands) Respiratory Skin Allergic/ Immunologic Blood/Lymph Please list the date and type of surgeries you have had: Are you in good general health? Yes No Weight (lbs) Height (in) Height (ft) Are you pregnant or nursing? Do you have any allergies to medications or other substances? Yes No If yes, please list _
2 Name and phone number of your Primary Care Physician? List ALL major injuries or surgeries you have had and approximate dates: List any other medical conditions you have had, including non-drug allergies: List all RX and over-the-counter medications you currently take: List any vitamins or supplements you currently take: List any drug allergies you have: Smoking Status Alcohol Use Do you live alone? Yes No How much? Per Yes No How much? Per Yes No Assisted Living Nursing Home Current medications: (Please list names and how often) Do you or any of your relatives have a history of any of the following? High Blood Pressure Macular Degeneration Diabetes Do you have any of the following? Dry Eyes Eye Surgeries Wear Contacts/Glasses Retinal Detachment Relation: Glaucoma Cataracts Blurred vision Eye Injuries Itchy Eyes
3 Review of Systems Please list any problems that you are currently having anywhere, from head to toe: General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain) Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems) Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs) Respiratory (e.g., chronic cough, shortness of breath, wheezing) Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence) _ Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting) _ Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination) _ Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements) Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration) Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems) Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)
4 Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising) Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes) Ocular History Who was your previous eye doctor? When was your last eye exam? Check the box for any conditions that apply: You Mom Dad Sib Describe (type, when diagnosed, which eye (s), treatment, etc.) Glaucoma Macular Degeneration Retinal Problems Cataracts Lazy Eye/Eye Turn List any major eye injuries, infections or surgeries and approx. dates: List any other significant eye problems you have had: List all RX and over-the-counter eye medications you currently use: List any vision complaints you are currently having such as: Blurred vision, headaches, eyestrain, double vision, or losing your place when reading. Itching, burning, redness, pain sensitivity to light, watering, crusting or mucus discharge. Seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs. How many hours/day do you typically spend using a computer or other digital devices? If you are having complaints with computer work, how far is the monitor from your eyes?
5 How many hours/day do you typically spend reading books, magazines, etc.? What are your hobbies/sports activities? Do you have sunglasses? Do you have back-up glasses? Are you interested in contacts? Contact Lens Wearers Only What disinfecting solution do you use? How long do you usually wear your lenses? How often do you replace your lenses? How old is your current pair of contacts? I certify that the information I have provided is complete and accurate to the best of my knowledge. Signature Date Relation Thank you! To print this form, RIGHT-CLICK anywhere on this page and select Print
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PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
To make your Annual Wellness Visit as helpful as possible, we ask that you do the following:
Aspen Medical Group Crista Keller, M.D. Megan Press, M.D. Katherine Johnson, NP-C Susan Esmond, PA-C E. Kendrick Lane, PA-C To our valued Medicare Patients, Medicare will now be covering a free annual
LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
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HOW TO ADVOCATE FOR YOURSELF. Presented by: Melissa Sammons Hughes MD FAAP Lupus Foundation of America, GA Chapter Board of Directors, Former Member
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Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child
Gemcitabine and Cisplatin
PATIENT EDUCATION patienteducation.osumc.edu What is Gemcitabine (jem-site-a been)? Gemcitabine is a chemotherapy medicine known as an anti-metabolite. Another name for this drug is Gemzar. This drug is
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER
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Workman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken