Little Rock Diagnostic Clinic Rheumatology - Patient Questionnaire
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- Mervin Rich
- 8 years ago
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1 Office Use nly Dctr: LRDC Chart #: Appintment Date: Little Rck Diagnstic Clinic Rheumatlgy - Patient Questinnaire This infrmatin will becme part f the medical recrd and is subject t federal privacy laws. Full Name: Date f Birth: address: Cell Phne: Circle all that apply: tbacc use high bld pressure diabetes heart disease Describe the medical prblem r reasn that yu are here fr evaluatin tday. When did it start? Hw lng des it last? Where is it lcated? Hw severe is it? Hw ften des it ccur? Aggravated by? Relieved by? Vitals This bx will be cmpleted by the nursing staff at the Prvider s ffice Please DO NOT write. Ht WT Temp BP Pulse Resp Pulse x
2 Please list the medicatins yu are currently taking. Please include all ver-the-cunter and herbal medicatins (use back f page if needed): Medicatin Name Dsage Hw ften Started Prblem medicatin fr Dctr wh wrte Pharmacy Name and Address D yu get yur medicatins fr 30 days r 90 days at a time? (circle ne) 30 days 90 days Please list any drug allergies r side effects (use back page if needed) When Drug Describe Reactin Immunizatins (list date f last) Tetanus Pneumnia Shingles Flu List all the physicians that yu are currently seeing: Physician Name Specialty Cnditin being treated Next Office Visit Wuld yu like a cpy f yur visit sent t this dctr? 2 P a g e
3 Review f Systems- MEN ONLY Please check a bx belw fr every questin that applies t yur current health General N Yes Urinary N Yes Skin N Yes Chills Dribbling Brittle hair Fatigue Painful urinatin Brittle nails Fever Bld in urine Hair lss Night sweats Excessive urinatin Excessive hair grwth Tired Slw stream Hives Weight gain Increased frequency Itching Weight lss Unable t hld urine Mle changes Truble emptying bladder Rash Skin lesin Head/Neck N Yes Reprductive N Yes Ear drainage Erectin prblems Ear pain Discharge frm penis Musculskeletal N Yes Eye discharge Decreased libid Back pain Eye pain Jint pain Hearing lss Jint swelling Nasal drainage Metablic N Yes Muscle weakness Sinus pressure Cld intlerance Neck pain Sre thrat Heat intlerance Visual changes Always thirsty Always hungry Bld/lymph N Yes Easy bleeding Respiratry N Yes Easy bruising Chrnic cugh Neurlgical N Yes Enlarged lymph ndes Recent cugh Dizziness Knwn TB expsure Numbness in arms/legs Shrtness f breath Weakness in arms/legs Immunity N Yes Wheezing Truble walking Cntact allergy Headache Envirnmental allergy Memry lss Fd allergy Heart N Yes Seizures Seasnal allergy Chest pains Tremrs Leg pain with walking Swelling in legs Heart racing Psychiatric N Yes Anxiety Depressin Gastrintestinal N Yes Truble sleeping Abdminal pain Bld in stls Change in stls Cnstipatin Diarrhea Heartburn Lss f appetite Nausea Vmiting 3 P a g e
4 Review f Systems- WOMEN ONLY Please check a bx belw fr every questin that applies t yur current health General N Yes Urinary N Yes Psychiatric N Yes Chills Painful urinatin Anxiety Fatigue Bld in urine Depressin Fever Excessive urinatin Truble sleeping Night sweats Increased frequency Tired Unable t hld urine Weight gain Truble emptying bladder Metablic N Yes Weight lss Cld intlerance Heat intlerance Always thirsty Head/Neck N Yes Reprductive N Yes Always hungry Ear drainage Abnrmal pap smear Ear pain Painful perids Eye discharge Painful intercurse Musculskeletal N Yes Eye pain Ht flashes Back pain Hearing lss Irregular perids Jint pain Nasal drainage Vaginal discharge Jint swelling Sinus pressure Muscle weakness Sre thrat Neck pain Visual changes Skin N Yes Brittle hair Brittle nails Bld/lymph N Yes Respiratry N Yes Hair lss Easy bleeding Chrnic cugh Excessive hair grwth Easy bruising Recent cugh Hives Enlarged lymph ndes Knwn TB expsure Itching Shrtness f breath Mle changes Wheezing Rash Immunity N Yes Skin lesin Cntact allergy Envirnmental allergy Heart N Yes Fd allergy Chest pains Neurlgical N Yes Seasnal allergy Leg pain with walking Dizziness Swelling in legs Heart racing Numbness in arms/legs Weakness in arms/legs Truble walking Headache Gastrintestinal N Yes Memry lss Abdminal pain Bld in stls Change in stls Cnstipatin Diarrhea Heartburn Lss f appetite Nausea Vmiting Seizures Tremrs 4 P a g e
5 Past Medical Histry Place check all that apply t yu Allergies Bld clts Gallbladder disease Kidney disease Anemia Cancer (type) Heartburn/ reflux Seizures Chest pains COPD Hepatitis C Thyrid disease Anxiety Heart Disease High bld pressure Arthritis Depressin Irritable bwel disease Asthma Diabetes Mycardial infarctin Atrial fibrillatin Elevated lipids Osteprsis Past Surgical Histry Place the Year (if knwn) t all that apply t yu Year Year Men Only Year Wmen Only Year Heart Balln Gastric Bypass Prstate Bipsy Breast Implants Appendix Remval Hernia Repair Prstate Surgery Tubal Knee Scpe Hip Replacement Vasectmy Breast Bipsy Back Surgery Knee Replaced C-sectin Bld transfusin LASIK Eye D&C Heart Bypass ORIF Hysterectmy Cardiac Pacemaker Thyrid Remval Mastectmy Carpal Tunnel Tnsil Remval Fibrid Remval Cataract Remval Breast Reductin Intestine Remval Hyst and Ovaries Clstmy Bag Vaginal Hyst 5 P a g e
6 Family Histry Adpted/unknwn Alive (age) Deceased (at what age) Attentin Deficit Disrder Alchlism Allergies Alzheimer's disease Arthritis Asthma Bld disrder Cancer Type f cancer Heart disease after 50 Heart disease befre 50 Depressin Develpmental Prblems Diabetes Skin prblems Elevated lipids Genetic disease Hearing prblems High bld pressure Irritable bwel disease Learning prblems Mental illness Migraines Obesity Osteprsis Pr circulatin Kidney disease Seizures Strke Lupus Thyrid disrder Place a check mark in the bx t all that apply Mther Father Sister Brther Other Other relevant family histry: 6 P a g e
7 Scial Histry Tbacc Histry: Smking Tbacc Use Tbacc Use Usage Type: daily per day Years used Age started Age stpped Nn-Smking Tbacc Use Tbacc Use Usage per Type: Daily day Years used Age started Age stpped Cigarette #packs/cig Chewing units Cigarill cigarills Smkeless units Cigar cigars Snuff units Pipe pipes Have yu ever tried t quit smking? N / Yes Year quit? Cessatin methd? Lngest perid tbacc free? Relapsed? Yes / N If s, why? Alchl Histry: N Yes Frmerly (list year quit) Type f alchl Hw frequently Hw much a day? When was yur last drink? Caffeine Histry: Yes N if Yes Type? Servings Per Day Demgraphics: The Federal Gvernment requires us t cllect the fllwing infrmatin. This infrmatin is part f the medical recrd and is subject t privacy laws. Race (must chse ne): American Indian r Alaskan Native Asian Black r African American Native Hawaiian r Other Pacific Islander White Ethnicity (check ne) Hispanic Nn-Hispanic Primary Language Spken: Cuntry f Birth (if nt US): Hand Dminance: Right Left Ambidextrus Educatin: Highest level f Educatin: Any Degree btained: Emplyment: Emplyer: Occupatin: Emplyment Status: If Retired, Date: 7 P a g e
8 Military Experience: N Yes Branch: Years served: Dmestic: Current Marital Status (circle ne): Single Married Widwed Divrced Previusly widwed? N Yes Previusly divrced? N Yes Children? N Yes # Sns # Daughters Wh lives with yu? Sleep Patterns: Changes in sleep patterns: N Yes Average number f hurs f sleep per night: Truble falling asleep: N Yes Difficulty staying asleep: N Yes Frequent waking episdes at night: N Yes Disrupted breathing, gasping, gagging r N Yes chking fr air during sleep: Lifestyle: Activity level: Mderate Sedentary Vigrus Health club member: Nw Previusly Never Type f exercise: Exercise frequency: Hurs/week: Hbbies/Activities: Current Diet : Animals in the hme: N Yes Type Religius/Spiritual: D yu have a religius affiliatin? N Yes Religin name: Hme Envirnment/Safety: Smke detectrs in hme? N Yes Carbn mnxide detectrs in hme? N Yes Falls in the last year? N Yes Number f falls: Pl/spa at hme: N Yes Seat belt use? N Yes Recent Travel Out f state? Out f cuntry? Knwn expsure t disease? 8 P a g e
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REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please
NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:
FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA
PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING
Surgery Health Survey
Surgery Health Survey Name: Social Security Number: Date of Birth: Please tell us which physician(s) we should contact regarding your visit: REFERRING PHYSICIAN Name: Address: PRIMARY CARE PHSYICIAN Name:
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:
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Guardian's Last Name (if patient
SLEEP DISORDER ADULT QUESTIONNAIRE
SLEEP DISORDER ADULT QUESTIONNAIRE Name: Date: Date of Birth (month/day/year): / / Gender: ο Male ο Female Marital Status: ο Never Married ο Married ο Divorced ο Widowed Home Address: City: Zip: Daytime
1 5 0 K E N N E D Y D R I V E S O U T H B U R L I N G T O N, V E R M O N T 0 5 4 0 3 8 0 2 4 4 8 9 3 7 0 8 0 2 4 4 8 1 4 1 4 (F)
Worker s Compensation Intake Form : Name: DOB: Social Security Address: City ST Zip Home Phone: Alternate Phone: Occupation: Employer Name: Employer Contact: Do you see a primary care physician for your
CLINIC APPLICATION. Client Information
ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone
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
INSURANCE INFORMATION Policy/Subscriber: PARENT/LEGAL GUARDIAN AND EMERGENCY CONTACT INFORMATION Parent/Legal Guardian Name:
PATIENT INFORMATION Patient #: Gender: Date f Birth: Last Name: Age: First Name: Initial: Scial Security #: Address: City, State, Zip: Hme Phne: Wrk Phne: RESPONSIBLE PARTY Accunt # Patient Relatinship
Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone
DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address
Orthopedic Patient Information
Orthopedic Patient Information Please complete the following questionnaire. It is designed to assist our providers with your care and better understand your medical information. Please answer every section.
PATIENT SELF-ASSESSMENT FORM
PATIENT SELF-ASSESSMENT FORM Please complete the information below to the best of your ability. Personal Information Name: Address: City: State: Zip: Telephone: Email: Name of referring physician: Address:
3. Your copayment is expected at the time of visit. We accept cash, checks, Visa, MasterCard and Discover. We do not accept American Express.
We would like to welcome you as a patient and thank you for choosing Central Virginia Orthopaedics & Sports Medicine to provide your orthopaedic needs. It is our mission to provide you the highest level
Emory Eye Center New Patient Questionnaire
Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions
PATIENT HISTORY FORM
PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your
PREGNANCY RISK ASSESSMENT MONITORING SYSTEM (PRAMS) UTAH QUESTIONNAIRE
PREGNANCY RISK ASSESSMENT MONITORING SYSTEM (PRAMS) UTAH QUESTIONNAIRE First, we wuld like t ask yu a few questins abut the time befre yur new baby was brn. Please check the bx next t the best answer.
454-6 MEDICATION GUIDE ZUBSOLV (Zub-solve) (buprenorphine and naloxone) Sublingual Tablet (CIII) IMPORTANT: Keep ZUBSOLV in a secure place away from
MEDICATION GUIDE ZUBSOLV (Zub-slve) (buprenrphine and nalxne) Sublingual Tablet (CIII) IMPORTANT: Keep ZUBSOLV in a secure place away frm children. Accidental use by a child is a medical emergency and
PATIENT INFORMATION PATIENT ETHNICITY / RACE SPOUSE INFORMATION EMERGENCY CONTACT
Conway Orthopaedic & Sports Medicine Clinic, PA 550 Club Lane Conway AR, 72034 501.329.1510 Account #: : Patient's Name: Patient's Street Address: Apt #: of Birth: Patient's Mailing Address/PO Box: Sex:
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
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form
MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form Front Office Person calls in for a new patient appointment. o Never seen at SWAN o Previously Seen at SWAN The following
CALCAGNO AND ROSSI VEIN TREATMENT CENTER PATIENT INFORMATION SHEET. Last First Middle Name: Name: Initial: Male: Address: City: State: Zip:
CALCAGNO AND ROSSI VEIN TREATMENT CENTER PATIENT INFORMATION SHEET Last First Middle Initial: Male: Is this your legal name? Female: Yes / no If not, what is your legal name: Address: City: State: Zip:
PLEASE PRINT LEGIBLY
Patient Information PLEASE PRINT LEGIBLY Patients Name: Date of Birth: Sex: Patients Address: City: State: Zip: Home Phone: Cell: Work: Email: SSN: Employer: Occupation: Marital Status: Employed: Full
San Luis Dermatology & Laser Clinic, Inc.
San Luis Dermatology & Laser Clinic, Inc. Patient Name: Pharmacy Name: LOCATION Health History Intake Form The federal government has defined a complete electronic medical record (EMR) or electronic health
PATIENT DEMOGRAPHICS:
PATIENT DEMOGRAPHICS: Last Name: First: MI: Address: City: State: Zip: Please check off the phone numbers you would like us to call regarding appointment conformations. Home: Cell: May we leave a message?
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
Women s Continence and Pelvic Health Center
Women s Continence and Pelvic Health Center Committed to Caring 580-590 Court Street Keene, New Hampshire 03431 (603) 354-5454 Ext. 6643 URINARY INCONTINENCE QUESTIONNAIRE The purpose of this questionnaire
PATIENT HEALTH QUESTIONNAIRE: Urology
PATIENT HEALTH QUESTIONNAIRE: Urology Patient Name: Sex: M F Last, First, Middle Initial Email: Date of Birth: \ \ Age: Social Sec #: - - Type of visit: Consultation requested by another Physician Self-referred