4541 N. Josey Lane, Suite 140



4541 N. Josey Lane, Suite 140Carrollton, Texas 75010Office: 972-906-1055Fax: 972-956-0815PATIENT HISTORY QUESTIONNAIRE(Historia Cuestionario de Paciente)Date:What Doctor sent you to our office?Primary Care Physician (Doctor Primario) Office Number for PCP (Numero de telephone del Doctor)GENERAL INFORMATION (Informacion General)Name (Nombre):387858597075179755759707535231075972015474208597075109537520723657054754358362514600178661Age (Edad)Date of Birth (Dia de Nacimiento)(MM/DD/YYYY) Sex (Sexo)Race:SSN#2626209-676253304682-6750427146253715491428750533474Do you require an interpreter? Primary Language (Lenguae Primero) Home AddressCity/ StateZip CodeHome Phone #Alternate or Cellular #EmployerEmployer Phone#Email:505777519898115430501989812714625351381Pharmacy NamePharmacy Telephone Are you left-handed or right-handed?4019550169136Does your job involve heavy lifting or prolonged standing? Would you prefer to be contacted at work or at home?May we leave message with a family member at home or on your answering machine?Primary Insurance Member ID # Group # Secondary Insurance Member ID# Group# Subscriber's Name Date of Birth #1 Emergency ContactName (Nombre)RelationshipPhone ##1 Emergency ContactName (Nombre)RelationshipPhone #4541 N. Josey Lane, Suite 140Carrollton, Texas 75010Office: 972-906-1055Fax: 972-956-08151743075397736(What family member who will act as your advocate and update other family members on your health status if surgery is required)?Please identify all that applyNameOffice Phone #Cardiologist (Heart Doctor)Pulmonologist (Lung Doctor)PodiatristEndocrinologistOtherList Medications and current dosages (Including aspirin, vitamins, herbs etc.) List de medicamentos y dosis-incluyendo, aspirina, vitaminas, hierbas, etc.4674285-808575390741-78715Are you taking aspirin or other blood thinners (Coumadin/Warfarin)MEDICATIONAMOUNTHOW OFTENPast Medical History (Historia Clinica)(Please check the box and fill in the DATE, if any of the following apply to you) (List de todas enfermedades medicas y6331934823631fecha approximada)4541 N. Josey Lane, Suite 140Carrollton, Texas 75010Office: 972-906-1055Fax: 972-956-0815PATIENTMANAGING PHYSICIANFAMILYEXPLAIN(Who, Age)DiabetesIf you have diabetes:Do you take:How long have you had diabetes?Do you test your blood sugar every day?If yes, how many times /dayWhat are your blood sugar testing results? BreakfastLunchDinnerBedtimeHypertensionCancerStrokeKidney DiseasePhlebitis/Deep Vein ThrombosisVaricose Veins or leg ulcersSee page 6MiscarriageHeart troubleArthritisHIV, HepatitisConvulsion/SeizuresLupusyesnoyesno4541 N. Josey Lane, Suite 140Carrollton, Texas 75010Office: 972-906-1055Fax: 972-956-0815Lung DiseaseyesnoyesnoCrohn’s Disease or Ulcerative ColitisyesnoyesnoThyroid DiseaseyesnoyesnoPulmonary EmbolusyesnoyesnoHypercholesterolemiayesnoyesnoErectile dysfunctionyesnoyesnoPain in leg w/ walkingyesnoyesnoALLERGIES (Please list all known allergies and reactions)ALLERGENREACTIONHOSPITALIZATION/SURGERY HISTORY (Please list all past hospitalizations)NAME OF HOSPITALPURPOSE OF HOSPITALIZATIONDATESocial History: (Please check the box if any of the following apply to you)Alcohol Use (alcolicas)NeverOccasionallyModerate (2-3 drinks)DailyTobacco/ smoke (Fumar)NeverPreviously but quit smoking on:Current Smoker# of Years# Packs/DayTobacco/ SnuffNeverPreviously but quit on:Current4541 N. Josey Lane, Suite 140Carrollton, Texas 75010Office: 972-906-1055Fax: 972-956-0815NUTRITIONAL PROFILE (Please check Yes or No for each item)Appetite:(Please check one)YesNOHave you had a large weight loss within the past yearHave you had a large weight gain within the past yearAre you involved in weight loss program?Do you take nutritional supplements?Do you exercise regularly?ARE YOU EXPERIENCING ANY OF THE FOLLOWINGGENERALRESPIRATORYNEUROLOGICALGood HealthCough or Frequent ColdsFrequent HeadachesFatigueShortness of BreathLightheaded/DizzyFeverSpitting up BloodParalysisInsomniaAsthma/Wheezing?Emphysema/TBStressGASTROINTESTINALPSYCHIATRICEYESLoss of AppetiteLoss/ConfusionWear Glasses/ContactsNausea/VomitingNervous/DepressionGlaucoma or CataractsDiarrheaClaustrophobiaEARS, NOSE, MOUTH, THROATConstipationENDOCRINEEarachesBlood in StoolHormone Replacement TherapyHearing Loss/Ringing in EarsHEMATOLOGICAL/LYMPHATICExcessive Thirst or UrinationNosebleedsSlow Healing After cutsHeat/Cold ToleranceSinus ProblemsAnemiaINTEGUMENTARY / BREASTSore Throat or Mouth SoresBlood TransfusionRash/Itching4541 N. Josey Lane, Suite 140Carrollton, Texas 75010Office: 972-906-1055Fax: 972-956-0815Dental ProblemsBleeding/BruisingChange in skin/hair/nailsSwollen glands in neckBlood DisordersYellow JaundiceCARDIOVASCULARALLERGY/IMMUNOLOGICGENITOURINARYChest PainEnvironmental AllergiesFrequent UrinationPacemaker InsertionMUSCULOSKELETALPainful/Burning urinationIrregular/Fast HeartbeatJoint Pain/SwellingBladder Control ProblemsNumbness/Weakness ExtremitiesMuscle/Joint WeaknessKidney StonesSwelling of Feet/AnklesBack PainChange in Force/ SteamPain when walkingJoint StiffnessVenereal DiseaseFOR WOMEN ONLYFOR MEN ONLYBlood in UrineLast Menstrual PeriodTesticle PainHow many PregnanciesProstate ProblemsVein QuestionnaireDo you have any of the following: Varicose Veins - Bulging Veins - Spider VeinsWhich of the following are causing you concern? (Circle all that apply) Bulging Varicose Vein - Spider Veins - Leg Swelling4095750102461How long have your veins caused you problemsDoes your legs limit your daily activities due to discomfort Yes or NoDoes prolonged sitting or standing aggravate your veins Yes or No4541 N. Josey Lane, Suite 140Carrollton, Texas 75010Office: 972-906-1055Fax: 972-956-0815Have you ever noticed any of the following during activity or after prolonged standing? Aching Fatigue Swelling Itching Pain Burning Exercise Intolerance Have you ever had any of the following? (Check all that apply)Bleeding from Veins Slow or Non-Healing Skin Ulceration Darkening of Skin Have you ever been treated for ulcerations or blood clot in your legs? Yes or NoIf yes, what was Done?In the past months or years, how many of the following conservative treatments have you attempted?Compression Stockings Weight Loss Program Exercise Leg Elevation (Name)294322582539Bad Reactions to Anesthesia? YES NO N/AIf yes, please (Specify)* PLEASE USE THIS SPACE TO LIST ANY OTHER MEDICAL INFORMATION YOU FEEL IS NECESSARY AND WAS NOT ADDRESSED IN THE QUESTIONNAIRE485775137356To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status.Patient’sSignature: Date: Patient’s Name(Print): Date: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download