Medical History Form

Total Page：16

File Type：pdf, Size：1020Kb

Thank you for trusting us with your eye health care. We promise to do our best to provide you with the finest care available. If you have any questions, please do not hesitate to call us. MEDICAL HISTORY FORM Birthdate Patient Name Gender: Male / Female Today’s Date Primary Care Physician Current eye problem/symptoms? NONE / Routine Eye Exam Currently wear contacts? Yes / No Details Injury Related? If Yes, How did it occur? PAST MEDICAL HISTORY (Please circle all that apply or have applied for you) NONE Anxiety Coronary Artery Disease Hypothyroidism Arthritis Depression Leukemia Artificial joints Diabetes Lung Cancer Atrial Fibrillation End Stage Renal Disease Lymphoma Asthma GERD Pacemaker / Defibrillator Yes / No BPH Hearing Loss Prostate Cancer Bone Marrow Transplantation Hepatitis Radiation Treatment Breast Cancer Hypertension Seizures Colon Cancer HIV / AIDS Stroke COPD High Cholesterol Valve Replacement Other PAST SURGICAL HISTORY (Please list all Surgical Procedures / Hospitalizations and Year) NONE Year Year Year Year MEDICATIONS ALLERGIES (Please list all Allergies) NONE (Please list all current prescription & supplements) NONE PLEASE COMPLETE BOTH SIDES OF THIS FORM. THANK YOU OCULAR (EYE) HISTORY(Please list eye conditions and when treated) NONE Year Year Year OCULAR (EYE) SURGERY (Please list all eye surgical procedures and when) NONE Year Year Year FAMILY HISTORY (Please circle all that apply and indicate relation) NONE Relation Relation Relation Cataracts Blindness Migraine Diabetes Cancer Retinal Detachment Glaucoma CVA Strabismus Macular Degeneration (AMD) Heart Disease Other SOCIAL HISTORY (Please check all that apply) CIGARETTE SmOKIng: ALCOHOL USE: ILLICIT DRug USE: SAFETY: Never Smoked Alcohol: None None I feel safe at home Quit: Former Smoker Alcohol: < 1 drink / day Drug use I do not feel safe at home Smokes less than daily Alcohol: 1-2 drinks / day IV Drug use Smokes daily Alcohol: 3 or more drinks / day Other PEDIATRIC HISTORY (Complete only if child patient) Gestational Age at Birth: weeks Maternal illness during pregnancy: Birth Weight: lbs oz REVIEW OF SYSTEMS (Please circle all that apply) EYES/VISION CARDIOVASCULAR INTEgumENTARY Poor Vision High Blood Pressure Rash Eye Pain Rapid Heart Beat Changing Moles Tearing Redness RESPIRATORY NEUROLOGICAL Jaw Pain Congestion Headache Scalp Tenderness Wheezing Seizure Amaurosis Fugax Shortness of Breath Stroke Loss of vision Paralysis GASTROINTESTINAL G.I. EnDOCRINE Upset Stomach PSYCHIATRIC Diabetes Diarrhea Anxiety Hyperthyroid Constipation Depression Hypothyroid Burning on Urination Insomnia Urinary Frequency CONSTITUTION / SYSTEM Incontinence HEMATOLOGIC/LYmphATIC Fever Bleeding Chills MUSCULOSKELETAL Anemia Weight Loss Joint Pain Stiffness ALLERGIC/ImmunOLOGIC ENT AND MOUTH Arthritis Allergies Stuffy Nose Hay Fever Ear Ache Hives Cough Dry Mouth PLEASE COMPLETE BOTH SIDES OF THIS FORM. THANK YOU .

Copy Link

Recommended publications

New Patient Medical History Form
NEW PATIENT MEDICAL HISTORY FORM Full Name: Date: Birth Date: Age: ALLERGIES o NO ALLERGIES ALLERGY ALLERGIC REACTION MEDICATIONS MEDICATIONS DOSE TIMES PER DAY (Please list ALL) (Mg., pill, etc.) If you need more room to list medications, please write them on a blank sheet of paper with the required information HEALTH MAINTENANCE SCREENING TEST HISTORY CHolesterol Date: Facility/Provider: Abnormal Result? Y N Colonoscopy/SIGMOID Date: Facility/Provider: Abnormal Result? Y N Mammogram Date: Facility/Provider: Abnormal Result? Y N PAP SMEAR Date: Facility/Provider: Abnormal Result? Y N BONE density Date: Facility/Provider: Abnormal Result? Y N VACCINATION HISTORY Last Tetanus Booster or TdaP: Last Pnuemovax (Pneumonia): Last Flu Vaccine: Last Prevnar: Last Zoster Vaccine (Shingles): PERSONAL MEDICAL HISTORY DISEASE/CONDITION CURRENT PAST COMMENTS Alcoholism/Drug Abuse Asthma Cancer (type:_________________________________) Depression/Anxiety/Bipolar/Suicidal Diabetes (type:_______________________________) Emphysema (COPD) Heart Disease High Blood Pressure (hypertension) High Cholesterol Hypothyroidism/Thyroid Disease Renal (kidney) Disease Migraine Headaches Stroke Other: Other: SURGERIES TYPE (specify left/right) Date Location/Facility WOMEN’S HEALTH HISTORY Date of Last Menstrual Cycle: Age of First Menstruation: _____ Age of Menopause: _____ Total Number of Pregnancies: Number of Live Births: Pregnancy Complications: Patient Name: DOB: family MEDICAL HISTORY o NO Significant Family History IS KNOWN 4 CHECK ALL THat apply Stroke Cancer
[Show full text]
Cardiovascular Assessment
Cardiovascular Assessment A Home study Course Offered by Nurses Research Publications P.O. Box 480 Hayward CA 94543-0480 Office: 510-888-9070 Fax: 510-537-3434 No unauthorized duplication photocopying of this course is permitted Editor: Nurses Research 1 HOW TO USE THIS COURSE Thank you for choosing Nurses Research Publication home study for your continuing education. This course may be completed as rapidly as you desire. However there is a one-year maximum time limit. If you have downloaded this course from our website you will need to log back on to pay and complete your test. After you submit your test for grading you will be asked to complete a course evaluation and then your certificate of completion will appear on your screen for you to print and keep for your records. Satisfactory completion of the examination requires a passing score of at least 70%. No part of this course may be copied or circulated under copyright law. Instructions: 1. Read the course objectives. 2. Read and study the course. 3. Log back onto our website to pay and take the test. If you have already paid for the course you will be asked to login using the username and password you selected when you registered for the course. 4. When you are satisfied that the answers are correct click grade test. 5. Complete the evaluation. 6. Print your certificate of completion. If you have a procedural question or “nursing” question regarding the materials, call (510) 888-9070 for assistance. Only instructors or our director may answer a nursing question about the test.
[Show full text]
Patient/ Family History
Patient/ Family Mankato History Location: Mankato Fairmont New Prague Springfield St. James Waseca PATIENT PROVIDED INFORMATION The information you provide us will greatly help us to provide the highest quality and comprehensive care for you. Date Gender Male Female Date of birth (Month/Day/Year) A. PAST MEDICAL HISTORY 1. Have you ever traveled or lived outside of the United States or Canada? Do not know No Yes 2. Have you ever received a blood transfusion? Do not know No Yes (If yes, check all that apply.) Before 1980 1980-1990 After 1990 3. Have you received the following immunizations and/or had the disease? Pneumococcal (For pneumonia) Do not know No Yes Mumps Do not know No Yes Hepatitis B Do not know No Yes Rubella Do not know No Yes Hepatitis A Do not know No Yes Polio Do not know No Yes Measles Do not know No Yes Varicella (For chicken pox) Do not know No Yes 4. Indicate whether you have ever had a medical problem or surgery related to each of the following. Check all that apply. Medical Problem Surgery/Year Medical Problem Surgery/Year Eyes Lungs Ears Esophagus (Food or swallowing pipe) Nose Stomach (Ulcer) Sinuses Bowel (Small or large intestine, rectum) Tonsils Appendix Thyroid or parathyroid gland Lymph nodes Heart problems: Spleen Heart attack Liver Heart valves Gallbladder Abnormal heart rhythm Pancreas Narrowed coronary arteries Hernia Other Kidneys Arteries (Head, arms, legs, aorta, etc.) Bladder Veins or blood clots in the veins Bones ©2014 Mayo Foundation for Medical Education and Research Page 1 of 4 1081MR rev10/14 (Label) Patient Name DOB Unit No.
[Show full text]
Medical Staff Medical Record Policy
Number: MS -012 Effective Date: September 26, 2016 BO Revised:11/28/2016; 11/27/2017; 1/22/2018; 8/27/2018 CaroMont Regional Medical Center Author: Approved: Patrick Russo, MD, Chief-of-Staff Authorized: Todd Davis, MD, EVP, GMO MEDICAL STAFF MEDICAL RECORD POLICY 1. REQUIRED COMPONENTS OF THE MEDICAL RECORD The medical record shall include information to support the patient's diagnosis and condition, justify the patient's care, treatment and services, and document the course and result of the patient's care, and services to promote continuity of care among providers. The components may consist of the following: identification data, history and physical examination, consultations, clinical laboratory findings, radiology reports, procedure and anesthesia consents, medical or surgical treatment, operative report, pathological findings, progress notes, final diagnoses, condition on discharge, autopsy report when performed, other pertinent information and discharge summary. 2. ADMISSION HISTORY AND PHYSICAL EXAMINATION FOR HOSPITAL CARE Please refer to CaroMont Regional Medical Center Medical Staff Bylaws, Section 12.E. A. The history and physical examination (H&P), when required, shall be performed and recorded by a physician, dentist, podiatrist, or privileged practitioner who has an active NC license and has been granted privileges by the hospital. The H&P is the responsibility of the attending physician or designee. Oral surgeons, dentists, and podiatrists are responsible for the history and physical examination pertinent to their area of specialty. B. If a physician has delegated the responsibility of completing or updating an H&P to a privileged practitioner who has been granted privileges to do H&Ps, the H&P and/or update must be countersigned by the supervisor physician within 30 days after discharge to complete the medi_cal record.
[Show full text]
GUIDELINES for WRITING SOAP NOTES and HISTORY and PHYSICALS
GUIDELINES FOR WRITING SOAP NOTES and HISTORY AND PHYSICALS by Lois E. Brenneman, M.S.N, C.S., A.N.P, F.N.P. © 2001 NPCEU Inc. all rights reserved NPCEU INC. PO Box 246 Glen Gardner, NJ 08826 908-537-9767 - FAX 908-537-6409 www.npceu.com Copyright © 2001 NPCEU Inc. All rights reserved No part of this book may be reproduced in any manner whatever, including information storage, or retrieval, in whole or in part (except for brief quotations in critical articles or reviews), without written permission of the publisher: NPCEU, Inc. PO Box 246, Glen Gardner, NJ 08826 908-527-9767, Fax 908-527-6409. Bulk Purchase Discounts. For discounts on orders of 20 copies or more, please fax the number above or write the address above. Please state if you are a non-profit organization and the number of copies you are interested in purchasing. 2 GUIDELINES FOR WRITING SOAP NOTES and HISTORY AND PHYSICALS Lois E. Brenneman, M.S.N., C.S., A.N.P., F.N.P. Written documentation for clinical management of patients within health care settings usually include one or more of the following components. - Problem Statement (Chief Complaint) - Subjective (History) - Objective (Physical Exam/Diagnostics) - Assessment (Diagnoses) - Plan (Orders) - Rationale (Clinical Decision Making) Expertise and quality in clinical write-ups is somewhat of an art-form which develops over time as the student/practitioner gains practice and professional experience. In general, students are encouraged to review patient charts, reading as many H/Ps, progress notes and consult reports, as possible. In so doing, one gains insight into a variety of writing styles and methods of conveying clinical information.
[Show full text]
Clinical Characteristics and Prognosis Of
Lyu et al. BMC Cardiovascular Disorders (2019) 19:209 https://doi.org/10.1186/s12872-019-1177-1 RESEARCH ARTICLE Open Access Clinical characteristics and prognosis of heart failure with mid-range ejection fraction: insights from a multi-centre registry study in China Lyu Siqi, Yu Litian* , Tan Huiqiong, Liu Shaoshuai, Liu Xiaoning, Guo Xiao and Zhu Jun Abstract Background: Heart failure (HF) with mid-range ejection fraction (EF) (HFmrEF) has attracted increasing attention in recent years. However, the understanding of HFmrEF remains limited, especially among Asian patients. Therefore, analysis of a Chinese HF registry was undertaken to explore the clinical characteristics and prognosis of HFmrEF. Methods: A total of 755 HF patients from a multi-centre registry were classified into three groups based on EF measured by echocardiogram at recruitment: HF with reduced EF (HFrEF) (n = 211), HFmrEF (n = 201), and HF with preserved EF (HFpEF) (n = 343). Clinical data were carefully collected and analyzed at baseline. The primary endpoint was all-cause mortality and cardiovascular mortality while the secondary endpoints included hospitalization due to HF and major adverse cardiac events (MACE) during 1-year follow-up. Cox regression and Logistic regression were performed to identify the association between the three EF strata and 1-year outcomes. Results: The prevalence of HFmrEF was 26.6% in the observed HF patients. Most of the clinical characteristics of HFmrEF were intermediate between HFrEF and HFpEF. But a significantly higher ratio of prior myocardial infarction (p = 0.002), ischemic heart disease etiology (p = 0.004), antiplatelet drug use (p = 0.009), angioplasty or stent implantation (p = 0.003) were observed in patients with HFmrEF patients than those with HFpEF and HFrEF.
[Show full text]
Medical History and Physical Examination Worksheet
U.S. Department of State OMB No. 1405-0113 EXPIRATION DATE: xx/xx/xxxx MEDICAL HISTORY AND PHYSICAL EXAMINATION WORKSHEET ESTIMATED BURDEN: 35 minutes For use with DS-2053 (See Page 2 - Back of Form) Name (Last, First, MI) Exam Date (mm-dd-yyyy) Birth Date (mm-dd-yyyy) Passport Number Alien (Case) Number 1. Past Medical History (indicate conditions requiring medication or other treatment after resettlement and give details in Remarks) NOTE: The following history has been reported, has not been verified by a physician, and should not be deemed medically definitive. No Yes No Yes General Ever caused SERIOUS injury to others, caused MAJOR Illness or injury requiring hospitalization (including psychiatric) property damage or had trouble with the law because of Cardiology medical condition, mental disorder, or influence of alcohol or drugs Angina pectoris Hypertension (high blood pressure) Obstetrics and Sexually Transmitted Diseases Pregnancy Fundal height cm Cardiac arrhythmia Last menstrual period Date (mm-dd-yyyy) Congenital heart disease Sexually transmitted diseases, specify Pulmonology History of tobacco use Current useYes No Endocrinology and Hematology Asthma Diabetes mellitus Chronic obstructive pulmonary disease (emphysema) Thyroid disease History of tuberculosis (TB) disease History of malaria Treated Yes No Other Current TB symptoms Yes No Malignancy, specify Neurology and Psychiatry Chronic renal disease History of stroke, with current impairment Chronic hepatitis or other chronic liver disease Seizure disorder Hansen's Disease
[Show full text]
The Contribution of the Medical History for the Diagnosis of Simulated Cases by Medical Students
International Journal of Medical Education. 2012;3:78-82 ISSN: 2042-6372 DOI: 10.5116/ijme.4f8a.e48c The contribution of the medical history for the diagnosis of simulated cases by medical students Tomoko Tsukamoto, Yoshiyuki Ohira, Kazutaka Noda, Toshihiko Takada, Masatomi Ikusaka Department of General Medicine, Chiba University Hospital, Japan Correspondence: Tomoko Tsukamoto, Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba city, Chiba, 260-8677 Japan. Email: [email protected] Accepted: April 15, 2012 Abstract Objectives: The case history is an important part of diag- rates were compared using analysis of the χ2-test. nostic reasoning. The patient management problem method Results: Sixty students (63.8%) made a correct diagnosis, has been used in various studies, but may not reflect the which was based on the history in 43 students (71.7%), actual reasoning process because a list of choices is given to physical findings in 11 students (18.3%), and laboratory the subjects in advance. This study investigated the contri- data in 6 students (10.0%). Compared with students who bution of the history to making the correct diagnosis by considered the correct diagnosis in their differential diagno- using clinical case simulation, in which students obtained sis after taking a history, students who failed to do so were clinical information by themselves. 5.0 times (95%CI = 2.5-9.8) more likely to make a final Methods: A prospective study was conducted. Ninety-four misdiagnosis (χ2(1) = 30.73; p<0.001). fifth-year medical students from Chiba University who Conclusions: History taking is especially important for underwent supervised clinical clerkships in 2009 were making a correct diagnosis when students perform clinical surveyed.
[Show full text]
The History of Medicine a Beginner’S Guide
The History of Medicine A Beginner’s Guide Mark Jackson A Oneworld Paperback Published in North America, Great Britain & Australia by Oneworld Publications, 2014 Copyright © Mark Jackson 2014 The right of Mark Jackson to be identified as the Author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988 All rights reserved Copyright under Berne Convention A CIP record for this title is available from the British Library ISBN 978-1-78074-520-6 eISBN 978-1-78074-527-5 Typeset by Siliconchips Services Ltd, UK Printed and bound in Denmark by Nørhaven Oneworld Publications 10 Bloomsbury Street London WC1B 3SR England Stay up to date with the latest books, special offers, and exclusive content from Oneworld with our monthly newsletter Sign up on our website www.oneworld-publications.com For Ciara, Riordan and Conall ‘A heart is what a heart can do.’ Sir James Mackenzie, 1910 Contents List of illustrations viii Preface x Introduction xiii 1 Balance and flow: the ancient world 1 2 Regimen and religion: medieval medicine 25 3 Bodies and books: a medical Renaissance? 50 4 Hospitals and hope: the Enlightenment 84 5 Science and surgery: medicine in the nineteenth century 120 6 War and welfare: the modern world 159 Conclusion 197 Timeline 201 Further reading 214 Index 221 List of illustrations Figure 1 Chinese acupuncture chart Figure 2 Vessel for cupping (a form of blood-letting) discov- ered in Pompeii, dating from the first century CE Figure 3 Text and illustration on ‘urinomancy’ or urine analysis Figure 4 Mortuary crosses placed on the bodies of plague victims, c.
[Show full text]
Guidelines and Discussion of the History and Physical Examination
GUIDELINES AND DISCUSSION OF THE HISTORY AND PHYSICAL EXAMINATION U.S. Department of Health and Human Services Centers for Disease Control and Prevention National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine April 16, 2012 Over 600,000 refugees have resettled in the United States over the past decade, with a steady increase in numbers since 2006 [1]. Refugees arrive from around the globe and settle throughout the United States. Depending on their country of origin, refugees are at increased risk for many diseases, both infectious and noninfectious, not commonly seen in the native US-born population. Conditions such as tuberculosis and sexually transmitted infections are particularly important to recognize early, given their potential public health consequences. The initial history and physical (H&P) examination is a critically important first step in the assessment of newly arrived refugees. A thoughtful H&P can both assist in identifying disease and help refugees develop a sense of trust in our medical system and in the care being provided (e.g., in many cultures a clinical encounter is viewed as useless if a physical examination is not performed during the visit). Given the complexity of the domestic medical screening visit, it is vital that clinicians set aside an adequate amount of time, create a trusting environment, and provide competent interpretation services to facilitate compassionate and culturally appropriate history acquisition and performance of the physical examination. Performing a History The first step in the examination of a newly arrived refugee is to obtain a detailed history, including any current symptoms, past medical problems, medications, allergies, social/family history, and a mental health assessment.
[Show full text]
The Oral Presentation Nersi Nikakhtar, M.D
Guidelines for the Oral Presentation Nersi Nikakhtar, M.D. University of Minnesota Medical School !1 Table of Contents The Oral Presentation: An Introduction ..................................3 Why Worry About the Oral Presentation? ...............................4 Presenting the New Patient .....................................................5 The Opening Statement ......................................................5 History of Present Illness ....................................................5 Past Medical History ...........................................................6 Medications/Allergies ..........................................................7 Social and Family History ...................................................7 Review of Systems ..............................................................7 Vitals .....................................................................................8 Physical Exam .....................................................................8 Labs and Studies .................................................................8 Summary Statement ............................................................8 Assessment and Plan ..........................................................9 The Follow Up (or Daily) Presentation: What's Different? ...................................................................11 The Outpatient (Known Patient) Presentation: What's Different? ...................................................................12 !2 The Oral Presentation: An Introduction The
[Show full text]
Medical Terminology Information Sheet
Medical Terminology Information Sheet: Medical Chart Organization: • Demographics and insurance • Flow sheets • Physician Orders Medical History Terms: • Visit notes • CC Chief Complaint of Patient • Laboratory results • HPI History of Present Illness • Radiology results • ROS Review of Systems • Consultant notes • PMHx Past Medical History • Other communications • PSHx Past Surgical History • SHx & FHx Social & Family History Types of Patient Encounter Notes: • Medications and medication allergies • History and Physical • NKDA = no known drug allergies o PE Physical Exam o Lab Laboratory Studies Physical Examination Terms: o Radiology • PE= Physical Exam y x-rays • (+) = present y CT and MRI scans • (-) = Ф = negative or absent y ultrasounds • nl = normal o Assessment- Dx (diagnosis) or • wnl = within normal limits DDx (differential diagnosis) if diagnosis is unclear o R/O = rule out (if diagnosis is Laboratory Terminology: unclear) • CBC = complete blood count o Plan- Further tests, • Chem 7 (or Chem 8, 14, 20) = consultations, treatment, chemistry panels of 7,8,14,or 20 recommendations chemistry tests • The “SOAP” Note • BMP = basic Metabolic Panel o S = Subjective (what the • CMP = complete Metabolic Panel patient tells you) • LFTs = liver function tests o O = Objective (info from PE, • ABG = arterial blood gas labs, radiology) • UA = urine analysis o A = Assessment (Dx and DDx) • HbA1C= diabetes blood test o P = Plan (treatment, further tests, etc.) • Discharge Summary o Narrative in format o Summarizes the events of a hospital stay
[Show full text]