Shirish A
Shirish A. Amin, M.D., P.C.
119 Professional Center, Suite 301
1265 Wayne Avenue
Indiana, PA 15701
724-465-6650
PATIENT ASSESMENT FORM
Patient’s Name_____________________________________________Date __________ ____
Reason for today’s visit:_________________________________________________________
|Have any of the following conditions ever been a significant problem for you? Please check √ |
|Condition |Yes |No |Condition |Yes |No |
|Mitral Valve Prolapse | | |Shortness of Breath | | |
|Heart Disease | | |Cough | | |
|High Blood Pressure | | |Asthma | | |
|Chest Pain | | |Bronchitis | | |
|Rheumatic Fever | | |Thyroid Disease | | |
|An Abnormal Cardiogram | | |Diabetes | | |
|Heart Attack | | |Low Blood Sugar | | |
|Anemia | | |Recent Weight Gain/Loss | | |
|Headaches | | |Loss of Urine | | |
|Seizures/Convulsions | | |Bladder Disease | | |
|Blurred Vision | | |Kidney Disease | | |
|Ringing in your Ears | | |Kidney Stones | | |
|Lightheadedness | | |Urinary Tract Infections | | |
|Difficulty Sleeping | | |Stomach Pains | | |
|Arthritis | | |Nausea and/or Vomiting | | |
|Leg Cramps | | |Loss of Appetite | | |
|Back Pain | | |Gallbladder Disease | | |
|Phlebitis/Blood Clots | | |Change in Bowel Habits | | |
|Numbness in Hands or Feet | | |Diarrhea/Constipation | | |
|Skin Lesions | | |Colitis | | |
|Poor Healing | | |Ulcer Disease | | |
|Easy Bruising | | |Yellow Jaundice | | |
|Family History of Cancer | | |Hepatitis | | |
|Do You Have a ….. Do You Have a ….. |
|History of Smoking | | |History of Stress | | |
|History of Alcohol or Drug Problems | | |History of other Emotional Problems | | |
|History of Anxiety | | |History of Tattoos | | |
|History of Depression | | |Other (Please Comment): | | |
Family History________________________________________________________
Please complete other side ((((((((((((((((((((((((((((((((((((((((((((((((
|Medications – Please Print Names of Medications and Dosage: |
|Medications |Dose |Times |Medications |Dose |Times |
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|Please List Allergies to Medication |
|Medications |Side Effects |Medications |Side Effect |
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|Previous Surgery Information |
|Type of Surgery |Date |Type of Surgery |Date |
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|Previous Medical History: |
|Medical Condition |Date of Onset |Medical Condition |Date of Onset |
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Patient Physician Information
Referring Physician____________________ Phone____________________
Address _______________________________________________________
Please list any other Physicians you see with their address:
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