Medical Intake Form. Name Age Birthdate Sex. Address City Zip. Phone (H) (W) Occupation Full Time / Part Time. Employer Education Level
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- Darrell Gallagher
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1 Medical Intake Form Please complete all of the following as accurately as possible: Name Age Birthdate Sex Address City Zip Phone (H) (W) Occupation Full Time / Part Time Employer Education Level Married Separated Divorced Widow Single Other Children (ages) How did you hear about us? Are you familiar with Homeopathy? What is the Level of Your Health? Excellent Good Fair Poor Please list your most concerning health care problems at this time (in order of importance to you): When did your chief problem or illness begin? What do you think may have caused your chief complaint? What experiences in your life have affected you deeply? Page 1 of 6
2 Past Surgical History: Please list any Surgical Procedures you have had and the approximate dates: Problem Dates Past Medical History: Please list any serious medical conditions for which you have been treated / hospitalized in the past: Problem Dates Specifically, please place a check next to any of the following that you have had: Heart Disease Stroke Diabetes Hypertension Asthma Allergies Eczema Depression Sexually Transmitted Disease HIV / AIDS Tuberculosis (TB) Polio Cancer Major Trauma Page 2 of 6
3 Family History: Please Circle any of the following diseases tend to run in your family and list what relative (father, grandmother, etc.) Diabetes: Heart Disease: Stroke: High Blood Pressure: Seizures: Cancer: Asthma: Allergies: Eczema: Blood disorder: Social History: Please check beside any of the following you have used in the past or currently: Alcohol (beer, wine or spirits) Illegal Drugs Birth Control Pills Vitamins / Supplements Tobacco (cigarettes, cigar, pipe) Tobacco (chewing) Coffee Herbal Products Medications: List all of the Prescription Medicines or Over the Counter Drugs you are now taking: Allergies: Please list any medications to which you are allergic: Please list any foods that you are allergic or sensitive: Food Cravings: Please list any strong food cravings or favorite foods: Please list any strong food aversion or foods you avoid: Page 3 of 6
4 Review of Systems: Please put a check in the space next to any symptoms you currently have, or have had in the past: General: Warm blooded person Chilly person Tend to perspire easily Sensitive to wind Thirsty No thirst Weight loss or gain Affected by change in weather HEENT: Headaches Hair Loss Head Injury Seizures Dizziness Vertigo Balance Problem Hearing Problem Ringing in Ear Sensitive to Noise Ear Infections Discharge from Ear Retina Problems Wear Glasses Glaucoma Cataracts Eye Problem Sensitive to Light Sinus infections Nose Allergy Loss of Smell Frequent cavities Teeth problems Grinding the teeth Mouth Ulcers Gum problems Taste in mouth Loss of taste Sore throats Swallowing problem Tonsillitis Loss of voice Neck: Neck Injury Neck Pain Thyroid Problem Swollen glands Respiratory: Asthma Pneumonia Bronchitis Persistent Cough Wheezing Phlegm (frequent) Short of Breath Fluid in Chest Page 4 of 6
5 Heart: Heart Attack Angina Heart Valve Problem Chest Pain Chest Tightness Palpitations Irregular Heartbeat Ankle or leg swelling GI: Stomach Ulcer Gastritis Reflux Heartburn Frequent Nausea Frequent Vomiting Indigestion Belching Gas Bloating Diarrhea Tendency Constipation Tendency Blood in Stool Hemorrhoids Fissures Rectal Itching Parasites Liver Problems GU: Frequent Urination Painful Urination Difficulty urinating Male Prostate problems Erection problems Discharge from Penis Female Vaginal discharge Few or No orgasms Painful Intercourse Vaginal itching Premenstrual Syndrome (PMS) Heavy periods Irregular periods Age menstruation began: How frequent are periods: every days Waking to Urinate Incontinence Blood in Urine Testicle pain or swelling Infertility Varicocele Long lasting periods Bleeding between periods Fibroids Ovarian Cysts Endometriosis Menopausal problems How long do Periods usually last? days Page 5 of 6
6 Number of Pregnancies Number of Births Miscarriages Abortions Musculoskeletal: Muscle pain Joint pain Bone pain Broken Bones Numbness or Tingling Weakness in arms/legs Skin: Rough or Dry skin Rashes Itching Warts Hives Boils / Abcesses Acne Nail problems Sleep: Difficulty falling asleep Nightmares Waking frequently Waking too early Sleep apnea Mental / Emotional Memory problems Confusion Difficulty Concentrating Impulsive Restlessness Nervousness / Anxiety Strong fears Irritability Anger problems Mood Swings Depression / Sadness Hallucinations Feelings of Euphoria Please list any specific Fears that you have: Please provide any further clarifying information here: Page 6 of 6
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p In order for us to obtain a complete medical history, it is important for you to fill out this form in its entirety. Every item needs to be filled out. This information will be entered into our Electronic
Lighthouse IF YOU WERE THE DRIVER OF YOUR OWN VEHICLE, SOMEONE ELSE S VEHICLE OR A PASSENGER IN THE VEHICLE, ANSWER THIS SECTION COMPLETELY.
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Patient Medical History Form
Patient Medical History Form Patient Name: To help the doctor serve you better, please complete the information below. Thank you! Allergies: No known Allergies (If yes, please list all Drug, Food, and
CONSULTATION & CONSENT FORMS p. 1 of 5 C J HERBAL REMEDIES, INC. ********************************************************************************
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Gastroenterology Specialists of Delaware, LLC
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17191 St Luke s Way Suite 220 The Woodlands TX 77384
Dear Patient: Thank you for choosing Dr. Menga for your Rheumatology care. In order to expedite the check in process, please review and complete all enclosed documents prior to your appointment. Please
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