CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850
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1 CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY TELEPHONE: (607) FAX: An appointment has been arranged for you in our office located at 310 Taughannock Blvd, Suite 5B, Ithaca, NY, Directions to Island Health: Located next to Chemung Canal Trust Company Branch Office (formerly the Station Restaurant). From West Buffalo Street, turn onto Route 89 North. Our building is immediately on the left. Go in the south side entrance, take the elevators to the 5 th floor. It will help us provide faster and better service if you fill out the following pages of information. Completing this form will simply provide us some information about why you are coming, and about your past and current health status. Please bring the form with you to your appointment, or we will need you to fill it out again. Thank you, Geoffrey E. Moore, MD, FASCSM Shannan Simkin, NP Lisa Proctor, NP Items to bring: o Medical records from your referring provider o Any recent Lab test results- such as cholesterol, glucose and thyroid o Cardiovascular Risk Assessment (see attached instructions) o Loose-fitting clothing - 1 -
2 Name: Date of Birth: Today's Date: Tells us what your main problem is. That is, why you are coming to see us: Who is your referring provider? Tell us about your medical history. Please indicate whether you do or don t have a history of these items: Yes No Problem History Cancer Diabetes High Blood pressure High Cholesterol Heart Disease Mental illness Obesity Osteoarthritis Osteoporosis Rheumatoid arthritis Stroke Thyroid disease other What is your occupation? What is your current employment status? How many people live in your household? How many children do you have/are in your house? Tell us about your family health history. Did anyone have any of the below medical problems and if so, tell us who had it :Family includes cousins, aunts ect. Yes No Problem Family Member Cancer Diabetes High Blood pressure High Cholesterol Heart Disease Mental illness Obesity Osteoarthritis Osteoporosis Rheumatoid arthritis Stroke Thyroid disease other Tell us about your Surgery History and medically related events and their date of occurrence: Check off if it was surgery or an event, write down what it was, tell us the date it occurred
3 Surgery Medical Event Problem Date Please list any medications you are taking with the following information on each medication: Medication Dose Frequency Please list any drug allergies you have and tell us what happens to you if you get an allergic reaction Please list any food allergies you have and tell us what happens to you if you get an allergic reaction Please tell us if you have a latex allergy and tells us what happens to you if you get an allergic reaction Please answer yes or no below as to whether you have any of these problems: Yes No Problem Poor appetite Weight loss Fevers Night sweats/hot flashes Can t fall asleep Can t stay asleep Vision loss Yes No Problem - 3 -
4 Seeing flashes Hearing loss Ringing in the ears Shortness of breathe ( at rest) Shortness of breathe only while doing any activity ( of any kind) Waking up short of breathe Fatigue Can t keep warm Can t keep cool Swelling in hands/feet/legs Chest pain or discomfort Heartburn Chronic Diarrhea Chronic constipation Bloody stools Tar-like stools Pain in thigh(s) Frequent urination Night-time urination ( getting up 2 times per night or more) Penile/vaginal discharge Back pain Joint pain Non-healing skin lesions New/growing skin lesions Depression Anxiety Thoughts about suicide Weakness in arms/legs/hands/fingers Numbness Frequent/severe headaches Other Would you consider yourself to be overweight/heavy? If so, circle one, telling us if you have been overweight/heavy since: Childhood adolescence young adult marriage pregnancy menopause retirement Tell us about your weight gain by circling a choice below. Has it been: Gradually constant episodic and creeping upwards related to an event in your life up and down(yo/yo) Tells us about your history of dieting by circling all choices that fit you. Have you tried: Atkin s South Beach Weight watchers Meal substitutes Dietician/physician supervised diets Other: None Tell us how many meals a day you eat by circling a choice: 0-1 meal 2-3 meals 3-5 meals 5-7 meals What was your lowest ever, adult weight?: in lbs What was your highest ever, adult weight?: in lbs Do you do any physical activity? - 4 -
5 If so, tell us about how much physical activity in a day or week: Tell us about what type of activity/exercise you do: examples are walking, cleaning, ect: How long does this activity or exercise typically last? When you exercise, how do you feel and do you experience symptoms that differ from what you feel at rest? If so please list or describe what you feel when you exercise. Do you have any arthritis and if so, circle any choices to tell us where: Feet/ankle hips knees neck spine arms/shoulders/hands/fingers In regards to your sleep habits: tells us if you do any of the following. Circle all choices that apply: Less than 8 hours use CPAP machine sleep during day snore don t snore Tells us about your alcohol consumption by circling any choice: None 0-2 drinks per day greater than 2 drinks per day Tells us about your tobacco use or lack of use by circling any choice Have never used tobacco Former tobacco user considering quitting quit date established second hand exposure Do you use cigarettes or other tobacco products, and if so, please list: What age did you start? What age did you quit? Patient Signature: Date Thank you for taking the time to answer our questions. Your efforts allow us to be more prepared for your clinic visit. We ask you to please sign above, indicated that this information is accurate to the best of your ability. We look forward to seeing you in clinic. Sincerely, The Cayuga Center for Healthy Living Team - 5 -
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