Upload File

new patient health history 8-2016 · title: microsoft word - new patient health history 8-2016.docx...

  • Home
  • Documents
  • New Patient Health History 8-2016 · Title: Microsoft Word - New Patient Health History 8-2016.docx Created Date: 20160915154625Z
2
New Patient Health History Revised August 2016 TB Name:__________________________________________ University ID:____________________________________ Date of Birth: _____/_____/_____ Sex: M: F: Marital Status: Single: Married: Divorced: Long-term illness or condition, or any problem requiring regular treatment/care? (stomach, heart, headaches, weight, mental health/depression, blood pressure, asthma, etc.) None: If yes, please list:___________________________________ ________________________________________________ ________________________________________________ Allergies to Medications: None: If yes, please list:___________________________________ ________________________________________________ Other Allergies: Seasonal: Other: None: If yes, please list:___________________________________ ________________________________________________ Current Medications (name, dose) : None: Prescriptions (Includes Birth Control):__________________ ________________________________________________ ________________________________________________ Over the counter/herbal:____________________________ ________________________________________________ Past history of serious illness or trauma (broken bones, concussions, pneumonia, etc.) : None: If yes, please list:___________________________________ ________________________________________________ Has anyone in your family had: cancer, heart disease, high blood pressure, diabetes, thyroid problems, mental illness, or other inherited conditions? None: If yes, please list relative & condition:___________________ ________________________________________________ ________________________________________________ ________________________________________________ Past surgeries and/or hospitalizations (please list with date): __________________________________________ ________________________________________________ ________________________________________________ Tobacco/Nicotine Use: Never: Past: Current: Type: Cigarettes/Cigar/Pipe: Smokeless: Vaping: Quit when?: _________________________________________ How many?:_________________ Per:_____________________ How long?: _________________________________________ Alcohol Use: How many drinks do you average in a day? ______ A week? ______ How often do you binge drink (more than 4-5 drinks in one night? _________________________________________________ Street/Recreational/Illicit Drug Use: No: Yes: IV Drug Use: No: Yes: What kind?: _________________________________________ How much?: _________________________________________ How long?: __________________________________________ Screening for anxiety and depression: Over the past 2 weeks, how often have you been bothered by any of the following items? Not at all Several days More than half the days Nearly every day 1. Feeling nervous, anxious or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Little interest or pleasure in doing things 0 1 2 3 4. Feeling down, depressed, or hopeless 0 1 2 3 Females Only : # of pregnancies: _____ # of live births: _____ Menses regular? No: ☐ Yes: ☐ First day of last menstrual period? _______/_______/_______ Signature: ____________________________________________ Date:______/______/______

Upload: others

Post on 12-Jul-2020

2 views

Category:

Documents


0 download

Report

TRANSCRIPT

Page 1: New Patient Health History 8-2016 · Title: Microsoft Word - New Patient Health History 8-2016.docx Created Date: 20160915154625Z

New Patient Health History

Revised August 2016 TB

Name:__________________________________________

University ID:____________________________________

Date of Birth: _____/_____/_____ Sex: M: � F: �

Marital Status: Single: � Married: � Divorced: �

Long-term illness or condition, or any problem requiring regular treatment/care? (stomach, heart, headaches, weight, mental health/depression, blood pressure, asthma, etc.) None: �

If yes, please list:___________________________________

________________________________________________

________________________________________________

Allergies to Medications: None: �

If yes, please list:___________________________________

________________________________________________

Other Allergies: Seasonal: � Other: � None: �

If yes, please list:___________________________________

________________________________________________

Current Medications (name, dose ) : None: �

Prescriptions (Includes Birth Control):__________________

________________________________________________

________________________________________________

Over the counter/herbal:____________________________

________________________________________________

Past history of serious illness or trauma (broken bones , concuss ions , pneumonia , e t c . ) : None: �

If yes, please list:___________________________________

________________________________________________

Has anyone in your family had: cancer, heart disease, high blood pressure, diabetes, thyroid problems, mental illness, or other inherited conditions? None: �

If yes, please list relative & condition:___________________

________________________________________________

________________________________________________

________________________________________________

Past surgeries and/or hospitalizations (please list with date): __________________________________________

________________________________________________

________________________________________________

Tobacco/Nicotine Use: Never: � Past: � Current: �

Type: Cigarettes/Cigar/Pipe: � Smokeless: � Vaping: �

Quit when?: _________________________________________

How many?:_________________ Per:_____________________

How long?: _________________________________________

Alcohol Use:

How many drinks do you average in a day? ______ A week? ______

How often do you binge drink (more than 4-5 drinks in one night? _________________________________________________

Street/Recreational/Illicit Drug Use: No: � Yes: �

IV Drug Use: No: � Yes: �

What kind?: _________________________________________

How much?: _________________________________________

How long?: __________________________________________

Screening for anxiety and depression: Over the past 2 weeks, how often have you been bothered by any of the following items?

Not at all

Several days

More than half the days

Nearly every day

1. Feeling nervous, anxious or on edge

0 1 2 3

2. Not being able to stop or control worrying

0 1 2 3

3. Little interest or pleasure in doing things

0 1 2 3

4. Feeling down, depressed, or hopeless

0 1 2 3

Females Only : # of pregnancies: _____ # of live births: _____

Menses regular? No: ☐ Yes: ☐

First day of last menstrual period? _______/_______/_______

Signature: ____________________________________________

Date:______/______/______

Page 2: New Patient Health History 8-2016 · Title: Microsoft Word - New Patient Health History 8-2016.docx Created Date: 20160915154625Z

<<<<< CONFIDENTIAL MEDICAL INFORMATION >>>> Please retain a copy for program application

Boise State University Athletic Training Program (ATP)

HEALTH PHYSICAL

Name Date

Current Street Address:

City State Zip Code

Date of Birth Age Year in school

-----------------------------------------------------------------------------------------------------------------------------------------------------------

corrected uncorrected

HEIGHT: (in.) WEIGHT: (lbs.) VISION: R / L /

BLOOD PRESSURE: GENDER: male female

------------------------------------------------------------------------------------------------------------------------------------------------------------

GENERAL HEALTH EXAM NORMAL ABNORMAL FINDINGS

EYES

EARS, NOSE, THROAT

CARDIOVASCULAR

ABDOMEN

GENITALIA: hernia

SKIN

MD’s INITIALS

COMMENTS:

------------------------------------------------------------------------------------------------------------------------------------------------------------

ORTHOPEDIC EXAM NORMAL ABNORMAL FINDINGS

NECK

BACK

RIGHT SHOULDER

LEFT SHOULDER

RIGHT ELBOW

LEFT ELBOW

WRIST/HANDS

RIGHT HIP

LEFT HIP

RIGHT KNEE

LEFT KNEE

RIGHT ANKLE

LEFT ANKLE

FEET

NEUROMUSCULAR

PROVIDER COMMENTS or RECOMMENDATIONS:

FOLLOW-UP PROCEDURES REQUIRED Yes No

ATP PARTICIPATION APPROVED Yes No

DOCTOR’S SIGNATURE: ____________________________________________________ Date: ______________


By Judy Valdez PATIENT HEALTH & MEDICAL HISTORY. Provide information pertinent to the etiology and diagnosis of oral conditions and the total patient

New Patient Health History Form - Kovacs Chiropractic

DENTAL PATIENT HEALTH HISTORY...Patient or Guardian signature:_____ Date: _____ ... that I will not be considered a patient of record unless this examination is completed. ... orthodontics,

NEW PATIENT HEALTH HISTORY AND PAIN QUESTIONNAIRE Patient

New Patient Health History · 2018-11-17 · New Patient Health History Revised August 2016 TB Name ... You must provide a copy of doctor or healthcare provider record(s) for the

Step 1 - Patient Registration - Personal Information · Step 5 - Patient Health History - Medical Medical History Information page 3 of 3 Joseph Zimmer DDS X Date Although dental

The Digital Asthma Patient: The History and Future of ......1 The Digital Asthma Patient: The History and Future of Inhaler Based Health Monitoring Devices Dimitrios Kikidis 1, Dr

NRHS Patient History Preventive Health · 2017. 7. 27. · Name: DOB: NRHS Patient History Preventive Health Immunization Date Performed Annual Lab (In the past year) Influenza Vaccination

PATIENT HISTORY:

The Digital Asthma Patient: The History and Future …...1 The Digital Asthma Patient: The History and Future of Inhaler Based Health Monitoring Devices Dimitrios Kikidis 1, Dr. Konstantinos

Health Science. Objectives Collect information needed for a patient history; Prioritize patient information; and Compile information and generate a report

CONFIDENTIAL PATIENT HEALTH HISTORY · CONFIDENTIAL PATIENT HEALTH HISTORY ... Asian/Black or African American / American Indian or Alaskan Native ... Nervousness Eye Disease or Injury

Patient Health History Form - Concentra

Health History and Registration · health history and registration patient information patient last name first middle nickname age sex: male female date of birth street address city

PATIENT HISTORY REVIEW

Dental Assistant Certification Patient Health History Form ... · AMERICAN SOCIETY OF ANESTHESIOLOGY (ASA) CLASSIFICATION CLASS ASA l: Normal health patient ... Candidate ID City

NEW PATIENT CHILD HEALTH HISTORY

Patient Health History-OPS Form 404 - Community … · Web viewPatient Health History (PEDIATRIC) Patient Health History (ADULT) Page 1 of 1 OPS Form 404 (Rev 00/00) Page 1 of 1 OPS

New Patient Health History Form...8126 S. Mingo Rd, Ste 300 Tulsa, OK 74133 (918) 664-3571 DrSchluter.com New Patient Health History Form Please allow our staff to photocopy your driver's

PATIENT HISTORY QUESTIONAIRE

My Health Record Guidelines for Pharmacists...Editing or deleting clinical documents 22 Standards of documentation 22 Access history 23 My Health Record and the patient 24 Patient

PATIENT HISTORY Tell us about your childkerrvillepediatricdentistry.com/KPD Patient Health History_2016.pdf · appointments, prophylaxis (professional cleanings), emergency evaluations,

New Patient Health History Form - Vortala

NEW PATIENT MEDICAL HISTORY PATIENT INFORMATION

Patient Health History Form - ProOrtho · ProOrtho Patient Health History Form- Page 4 REVIEW OF SYSTEMS Please mark the circle next to ANY symptoms you have experienced in the past

New Patient Health History Form - Clinton Dentistry

WU ADRC DATA INTEGRATION AND SHARING: …• Clinical Core – Patient demographic information, family history, health history, depression inventories, physical examination, standard

PEDIATRIC DENTISTRY - Clayton Kids Dentistry · Clayton Pediatric Dental Center Burton A. Horwitz, DDS, MSD Patient Information Patient Registration & Health History ... General Dentist

Chiropractic Case History/Patient Information · Patient Name_____ Date_____ Chiropractic Case Hx 3 HEALTH HISTORY List ALL major illnesses, injuries, falls, auto-accidents or surgeries

Ability Health Services & Rehabilitation, LP Patient History Form · 2019-08-13 · Revised: 01.01.17 ABILITY HEALTH SERVICES & REHABILITATION, LP PATIENT GUIDELINES AND CANCELLATION

Patient health history Form Spanish fileCancer** Colitis Diabetes Diverticulosis Enfisema

New Patient Health History...COVID‐19 ‐ PATIENT DISCLOSURE This patient disclosure form seeks information from you that we must consider before making treatment decisions in the

Patient Encounters and Billing Information...Dec 01, 2011  · CHAPTER 3 Patient Encounters and Billing Information 77 PATIENT HEALTH SURVEY Figure 3.2 Medical History Form

Patient History Form - Eye Doctor Rochester NYeyesonrochester.com/cmsb/uploads/patient-history-form.pdf · Patient History Form ... Multiple Sclerosis pterygium ... Contact your employer’s

HEALTH HISTORY & NEW PATIENT INTAKE FORMcounterstrain.com/wp-content/uploads/New-Patient-Packet-External-1… · INFORMED CONSENT and PATIENT AGREEMENT I, the undersigned, hereby