CLINICAL HISTORY FORM
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- Christian Collins
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1 CLINICAL HISTORY FOR Name: : of Birth: Age Today: rimary Care hysician: WEIGHT HISTORY Height: Weight Age of obesity onset: 0-2 years old 2-12 years old years old Young adult iddle Age regnancy How many years have you been at your present weight? Greatest single weight loss: How did you lose this weight? How long was it maintained? Do you exercise regularly? What activities? Were there any significant events that lead to the weight gain? Loss of a loved one Trauma, accident or illness Loss of employment Other: Bring in your most recent labs from your primary care physician. A recent cholesterol panel and glucose level would be most informative. If your labs have not been checked in a while, inquire about having them checked before our first visit.
2 HYSICAL HISTORY Have you been diagnosed with or have you ever experienced any of the following conditions? Y N Endocrinology Type I Diabetes (Insulin dependant) Type II Diabetes (Non-Insulin dependant) Hyperthyroid Hypothyroid Goiter Grave s Disease Neurological Numbness or tingling in the hands or feet Seizures Epilepsy ultiple Sclerosis (S) Skin Dermatitis Rashes Open sores soriasis Hematology Blood clots from an injury or accident Anemia DVT (Deep Vein Thrombosis/Active Thrombophlebitis in legs) Thrombocytopenia low platelets; bleeding problems Heparin exposure Coumadin use Iron supplements Hemophilia OB/GYN Hormone replacement Birth Control ill/atch Irregular periods Difficulty in conceiving Excessively painful periods
3 Y N Gastrointestinal GERD Heartburn Stomach (peptic ulcer) Duodenal ulcer Constipation Diarrhea Vomiting Colitis Irritable Bowel Syndrome Crohn s Disease Gallbladder Disease Gallstones (Cholelithiasis) Are you symptomatic? Inflammation/infection of gallbladder (Cholecystitis) Respiratory Asthma Chronic Bronchitis Sleep Apnea Sleep Apnea treated C-ap/Bi-ap Shortness of breath on exertion COD (Chronic Obstructive ulmonary Disease) Emphysema Cardiovascular Heart Attack (yocardial Infarction) Angina alpitations High Blood ressure (Hypertension) Stroke (CVS) ini-stroke (TIA) Chest ain Heaviness in chest Congestive heart failure eripheral vascular disease High cholesterol
4 Y N Infectious Disease Hepatitis A Hepatitis B Hepatitis C HIV ositive Liver Disease Genital-Urinary Recurrent urinary infection Kidney stones Kidney disease Renal/Kidney failure (dialysis) Gout Stress incontinence usculoskeletal Arthritis Back pain igraine headaches (describe): ain in weight bearing joints sychological Depression: edication: Bi-olar Disorder Anxiety Suicide attempt Anorexia Bulimia Cancer Lung Breast rostate Colon Lymphoma Other:
5 rovide any pertinent information which you feel will help the doctor in treating you. edications: Bring your medications with you to your first visit. List all prescription medications taken currently on a regular basis: Do you take aspirin on a regular basis? Brand edication Dosage Frequency Yes No Dosage Started Reason for taking Ordering hysician Are any of the above medications taken for hormone replacement or birth control? Yes AST SURGICAL HISTORY: Operation/rocedure Reason Hospital No
6 RIOR SURGICAL ROBLES: Describe all problems Anesthesia: Wound: Bleeding: Clotting: Fever: Other: Hospital SIGNIFICANT FAILY HISTORY: Check any family member who has suffered or experienced any of the following conditions =aternal =aternal Grandmother Grandfather Aunt(s) Uncle(s) other Father Sister(s) Brother(s) Hypertension Diabetes Arthritis Cardiac disease Stroke Lung disease Cancer Obesity Liver disease Early death DVT blood clots AST AJOR EDICAL HISTORY: ajor Illness Treatment hysician
7 GENERAL HISTORY: Do you smoke? Yes No Frequency/Amount per day and # of years: Do you drink alcohol? Yes No Frequency/Amount: Check if you use any of the following? Wheelchair Walker Do you use any drugs (non-prescription/over the counter/illicit? Drug Yes Oxygen No Frequency ALLERGIES: Are you allergic to any medication: Yes No edication Are you allergic to any foods? (dairy, wheat products, shellfish) Reaction Yes No Yes No List: Are you allergic to any materials? (latex, surgical tape, iodine) List: What was the date of your last physical examination? Significant findings:
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NEW PATIENT HISTORY Mark L. Prasarn, M.D. Date: Name: Age: Height: Weight: Pharmacy: Phar. Phone#: Primary Care M.D. Referring M.D.: What is your Chief Complaint? What makes the pain better? Neck Pain
Interventional Spine Pain Consultants, P.A. Initial Consultation Information
Interventional Spine Pain Consultants, P.A. Initial Consultation Information Date: / / Date of Birth / / Age: Name: Name of the provider that recommended you to our office? Name of your primary care doctor?
THE ROSOMOFF COMPREHENSIVE REHABILITATION CENTER A Department of Douglas Gardens Hospital 5200 NE 2 nd Ave, Miami, FL 33137
THE ROSOMOFF COMPREHENSIVE REHABILITATION CENTER A Department of Douglas Gardens Hospital 5200 NE 2 nd Ave, Miami, FL 33137 Phone: (305)532-7246 Fax: (305)795-8488 Email: rehabilitation@rosomoffcenter.com
PATIENT / VISIT INFORMATION PATIENT INFORMATION
PATIENT / VISIT INFORMATION PATIENT INFORMATION Name of Patient: Date of Birth: Date of Visit: VISIT INFORMATION Please complete this form in its entirety, and present it to the registration desk when
DATA CAPTURE FORM LIFE INSURANCE
DATA CAPTURE FORM LIFE INSURANCE APPLICANT 1 APPLICANT 2 Title First Names Surname Date of Birth Marital Status Address Telephone Email In which country were you born? In the last 2 years, have you lived
Patient Medical History
Cardiovascular Abnormal Electrocardiogram Aortic Stenosis Atrial fibrillation Cardiac arrest Chest pain Congestive heart failure Heart valve replacement Hypertension Murmur Heart attack Palpitations Peripheral