San Luis Dermatology & Laser Clinic, Inc.
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- Evelyn Hunt
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1 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 record (EHR) as containing four basic functions: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes. In 2009, as a part of the Economic Stimulus, the federal government began offering incentives to providers to encourage implementation of electronic health records. Providers must attest to demonstrating meaningful use every year to avoid payment adjustment. Providers have to show that they are meaningfully using their EHRs by meeting thresholds for a number of objectives. As part of the objectives we are asked to have our patients complete medical history questions, and demographics so that we may eventually qualify for meaningful use. Thank you for your cooperation in completing this information. Past Medical History: (please all that apply) Anxiety Arthritis Asthma Atrial fibrillation BPH Bone Marrow Transplantation Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Pacemaker Prostate Cancer Radiation Treatment Seizures Stroke Valve Replacement Other Reviewed by: MPH RJH JMR Date: Initials Page 1 of 5
2 Past Surgical History: (please all that apply) Appendix Removed(Appendectomy) Bladder Removed (Cystectomy) Mastectomy ( Right Left Both) Lumpectomy ( Right Left Both) Breast Biopsy( Right Left Both) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass Percutaneous transluminal coronary angioplasty (ptca) Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Joint Replacement Knee ( Right Left Both) Joint Replacement Hip ( Right Left Both) Kidney Biopsy Kidney Removed (Nephrectomy) (Right, Left) Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy TURP Skin Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed (splenectomy) Testicles Removed (Right, Left, Both) Uterus (Hysterectomy): Fibroids Uterus (Hysterectomy): Uterine Cancer Other Skin Disease History: (please all that apply) Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer Other Do you wear Sunscreen? Yes No SPF: Do you tan in a tanning salon? Yes No Page 2 of 5
3 Family History: Do you have a family history of Skin Cancer? Basal Cell Carcinoma Yes No Squamous Cell Carcinoma Yes No Do you have a family history of Melanoma? Yes No Mother Father Sister Brother Daughter Son Uncle Aunt Nephew Niece Grandmother Grandfather Grandson Granddaughter Other Medications: (Please enter all current medications, or attach legible list) *Include Strength and dosage* Example - Aspirin 81mg tablets 1 daily Allergies to Medications: (Please enter all drug allergies) ALERTS: (please Yes/No for the following) Alerts: Yes No Allergy to adhesive Allergy to lidocaine Allergy to topical antibiotic ointments Artificial heart valve Artificial joints within past two years Blood thinners Defibrillator MRSA Pacemaker Premedication prior to procedure Rapid heartbeat with epinephrine Pregnancy or planning a pregnancy History of blood transfusions Page 3 of 5
4 Social History: (please all that apply) Smoking Status: Never smoked Quit: former smoker Smokes less than daily Smokes daily Illicit Drug Use: Drug Use IV Drug Use Alcohol Use (ETOH) Safety: Alcohol: none Alcohol: less than 1 drink a day Alcohol 1-2 drinks a day Alcohol: 3 or more drinks a day I feel safe at home. I do not feel safe at home. Other Page 4 of 5
5 Review of Systems: Are you currently experiencing any of the following? (Please Yes/No for the following) Symptom Yes No Problem with bleeding Problems with healing Problems with scarring(hypertrophic or keloid) Rash Immunosuppression Hay fever Chest pain Fever or chills Night sweats Unintentional weight loss Thyroid problems Sore throat Blurry vision Abdominal pain Bloody stool Bloody urine Joint aches Muscle Weakness Neck stiffness Headaches Seizures Cough Shortness of breath Wheezing Anxiety Depression Other Symptoms: My Primary Care Physician is aware of my current Alerts & Symptoms Yes No PATIENT SIGNATURE Date: Thank you! Page 5 of 5
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Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
BREAST HEALTH HISTORY FORM
BREAST HEALTH HISTORY FORM Name Date of Visit: Date of Birth: Age: REFERRING PHYSICIANS: please include name, address and phone number of all physicians whom you would like to receive report of today s
Yes/No. Are You ALLERGIC to any medications? Please specify:
Current Medications: (please include over the counter medications and food supplements) Drug Name: Dose How often? Are You ALLERGIC to any medications? Please specify: Yes/No Past Medical History: Please
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM Today s Date: PERSONAL INFORMATION First Name: Last Name: MI: Address: City: State/Province:
NORTH DALLAS EYE ASSOCIATES
NORTH DALLAS EYE ASSOCIATES W. Stephen Ku, M.D. Steven L. Elieff, M.D. Russell W. Snook, M.D. R. Raj Gupta, M.D. Eye Physicians and Surgeons PATIENT INFORMATION Last Name First Name MI Sex (Circle One)
Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD
Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine
Mid-State Neurosurgery, P.C Back & Neck Pain Center
Mid-State Neurosurgery, P.C Back & Neck Pain Center Patient Name: Date of Birth: Heart HISTORY Attack OF PRESENT ILLNESS Stroke Seasonal Allergies Diabetes What is the reason for today s visit? When did
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
Thank you, we look forward to meeting you!
Thank you for choosing Primary Medical Group of Warwick. We look forward to meeting and caring for you in the near future. Please print, review and complete all of the following pages so that we can get