Microsoft word - patientinformationform _2_.doc

Please list all medications (even over-the-counter medications and herbal supplements). Note all strength and dosages. Bring this along with your visit. Do you know of any blood relative who has or had: (Circle and Give Relationship) Stroke ______________ Tuberculosis __________ Blood Disease _________ Arthritis _________ if diagnosed by a doctor, is it __________ Rheumatoid Arthritis ____________Osteoarthritis ________ High blood pressure _______________ Asthma ________________ Bleeding Tendency ____________ Heart Attack _______________ Epilepsy _________ Cancer _____________ What Kind of Cancer _____________ Diabetes _________ Kidney Disease _____________ Gout ________ Problems with back __________ Osteoporosis _______ Personal History
Present Occupation Are you working Now?  Yes  No  Full time  Part Time Past Occupation Unable to work since: Sports or hobbies Military service Have you ever smoked  yes  No  Cigarettes  Pipe  Cigars How many per day? For how many years did you smoke ____________ How long ago did you quit? Do you regularly drink alcohol __________ Occasionally ________ Is alcohol a problem for you? Where have you lived? (geographically) Describe your current residence  Apartment  Home How many levels Where is your bedroom/bathroom in the home Which of the following do you use?  cane  walker  electric cart  standard wheelchair  toilet riser What is the most difficult thing for you to do at home? Past History
Record the diseases, surgeries and injuries you have had Medications
Are you presently taking any of the following medications?
Name Any Drugs that you are ALLERGIC to:
Name of Drug Describe Reaction Describe any other allergies you have How is your appetite?  Good  Fair  Poor Have you  gained weight  lost weight ______ lbs in _____ months? Are you on a special diet?  Yes  No What kind? Patient Name DOB Medical Record # Date When did you first notice your symptoms? Do you have morning stiffness? For how long? Hours Do you become unusually fatigued in the afternoon or evening?  Yes  No At what time ____________ Does sunlight bother you or cause a rash?  Yes  No Do your hands get blue or white with cold?  Yes  No Have you had hair loss?  Yes  No Do you have significantly dry eyes?  Yes  No Mouth?  Yes  No Please list the joints which have been involved List names of physicians, podiatrists or chiropractors you have seen for arthritis and the approximate date of these evaluations. Have you taken any of the following drugs: (Circle Ones you have taken) Aspirin (Anacin, Ascriptin, Bufferin, Ecotrin) Codeine, Vicodin, (Hydrocodone), Lortab, Lorcet Disalcid, Salsalate, Monogesic, Trilisate Estrogens (Premarin, Estrace, Ogen, Evista) Muscle Relaxants (soma, Norflex, Flexeril, Paraton, Cyclobenzaprine) Voltaven (Diclofenac), Cataflam, Arthrotec Zostrix Cream (Capsaicin), Dolorac, Mobisyl Joint injections _______________ Which joints? __________________ Have you had physical therapy  Yes  No Specifically for arthritis?  Yes  No When ____________________ Did it help? ______________________ On a Scale of 1 to 10 How Would you Rate Your Pain
None | _____|_____|_____|_____|_____|_____|_____|_____|_____| Most Severe
1 2 3 4 5 6 7 8 9 10
PLEASE Do Not Write in the
Space Below
Have you had fever or chills recently?
Do you have frequent headaches?
Have you ever had a convulsion, fit or epilepsy?
Have you had a rash or other skin problem?
Have you had red or inflamed eyes?
Have you had pain or ringing in your ears?
Do you have trouble swallowing?
Have you ever had shortness of breath?
Do you have a chronic cough?
Have you ever had chest pain or tightness in your
chest?
Have you had a heart attack? (Year ____)
Do you frequently have stomach upsets?
Have you had any recent changes in your bowel
habits?
Have you ever had an ulcer? (Year _____)
Have you had intestinal bleeding or black or
tarry stools?
Have you had recent frequency or burning with
urination?
Do you have to get up frequently at night to
urinate? (how many times)
Have you ever passed a kidney stone? (Year
Are you sensitive to cold exposure than most
Have you been nervous or depressed?
To be answered by WOMEN only:
Has there been a change in frequency or amount
of your menstrual flow
Date of last
period
Date of last pap
smear (cancer
test?
Dexa or
 Yes  No
osteoporosis
If yes, date ________
screening
Where_______
Number of Pregnancies?
Number of Children born alive?
Cerner Patient Registration Information Sheet
Patient Information
Physician ____________ Appt. Date ___________ Appt. Time _________
Patient Name _______________________________ Suffix (circle one ) II III Jr. Sr.
Last First MI
Preferred Name _____________________ Maiden Name __________________
Title (Circle one)
Captain/Colonel/Doctor/Father/Lieutenant/Major/Reverend/Sister
Gender _____ Birth date ________ SS# __________________________
(month/date/year)
Marital Status (circle one) divorced/ legally separated/ married / single/widowed
Billing Address __________________________________________________
City _____________ State __________ Zip ______________
Home Phone __________ Work Phone _________ Work extension _____
Resides at Address _________________________________________
City ______________ State _________ Zip _________________
Employment status (circle one) Active Military Duty/ full time/ not employed/ part
time/ retired/ self employed/ unknown
Employer _________________________________________________
(If self-employed please state name of Company/or Occupation)
Employer address ____________________________________________
EMERGENCY CONTACT

Relationship to Patient ______________ Name _____________________
Home Phone ________________ Work Phone ____________ Work Extension _____
Primary Care MD________________ Please indicate (X) if no Primary Care MD_____
Referring MD________________ Please indicate (X) if no Primary Care MD ______
Special Needs (ex: patient in wheelchair, hearing impaired) _____________

RESPONSIBLE BILLING PARTY

Relationship to Patient ________________ Name ___________________
Gender _____ Birth date _______ SS# _____________________
Address _______________ City ___________ State ______ Zip ______
Home Phone _____________ Work Phone __________ Work Extension ________
Employment status (circle one) Active Military Duty/ full time/ not employed/ part
time/ retired/ self employed/ unknown
Employer _________________________________________________
(If self-employed please state name of Company/or Occupation)
Employer address ____________________________________________
First Insurance Information

Insured’s Relationship to Patient ____________ Name _______________
Gender _____ Birth date _______ SS# _____________________
Address _______________ City ___________ State ______ Zip ______
Home Phone _____________ Work Phone __________ Work Extension ________
Employment status (circle one) Active Military Duty/ full time/ not employed/ part
time/ retired/ self employed/ unknown
Employer _________________________________________________
(If self-employed please state name of Company/or Occupation)
Employer ____________________________________________
Insurance Company Name ___________________________________
Group Name _____________ Group # ____________ Effective date _________
Insured’s Policy/Certificate #______________ Patient’s Policy/Certificate # _______
________________________________________________________________________
Second Insurance Information
Insured’s Relationship to Patient ____________ Name _______________
Gender _____ Birth date _______ SS# _____________________
Address _______________ City ___________ State ______ Zip ______
Home Phone _____________ Work Phone __________ Work Extension ________
Employment status (circle one) Active Military Duty/ full time/ not employed/ part
time/ retired/ self employed/ unknown
Employer _________________________________________________
(If self-employed please state name of Company/or Occupation)
Employer ____________________________________________
Insurance Company Name ___________________________________
Group Name _____________ Group # ____________ Effective date _________
Insured’s Policy/Certificate #______________ Patient’s Policy/Certificate # _______

Source: http://www.mhsec.com/downloads/patientformrheum.pdf