15IFM07_Medical Symptoms Questionnaire_final_v2.indd



342900000Integrative Healthcare, Inc. 1630 Riggins Rd. Tallahassee, FL 32308 (850)878-4434 Fax: (850)878-4423Dear New Patient; Welcome to Integrative Health Care!You may wish to use Integrative Healthcare as your primary care provider or as a consultant for only one or more specific problems. We will gladly send information to your other healthcare providers at your request. PORTAL: You may wish to use our patient portal. You can send secure messages, receive a limited amount of records or reports, and make appointments through the portal. You should receive an invitation to enter to get an account on the patient portal. If you do not receive this you can find a link on our website and send a request. It is best to use portal messages or email only for problems that are not urgent as it may take a day or two before I reply. LAB TESTING: We at Integrative Healthcare provide regular primary care services and also take a functional medicine approach. This means we consider the balance of all of the body systems as well as mental and emotional factors. We provide special testing to help gain insights into causes of chronic problems. Functional Medicine may entail dietary and lifestyle changes, use of supplements or medical foods and sometimes prescription medications. WE TRY TO INFORM YOU OF COST OF TESTS BUT CANNOT GUARANTEE WHAT YOU MAY OWE IN CO-PAYS. We very much value your feedback and also your referral of friends and family who may benefit from our services. Please feel free to offer suggestions comments and criticisms through our website or to the staff.N. Elizabeth Markovich, APRN, DNP Alicia Craig-Rodriguez, APRN, DNP 1630 Riggins Rd. Tallahassee, FLA 32308Phone: 850-878-4434Website: Privacy Policy – Please Be Informed Of Your RightsYou have the right to see your entire medical record and to add a notation if you see any errors. This can be done during an appointment or you may schedule a time to come in and do this.A blanket consent form will be signed when you first register as a new patient. This is for general billing purposes and to give consent for treatment provided at this office.When additional medical records or information to treat you is needed by another health care professional, you will need to give consent by signature for this office to release those records by mail, fax computer or telephone.Any records sent or discussed will be only those needed for the health problem at hand. This is called a “minimal disclosure”. The whole record will not be sent unless it is specifically requested and needed for that purpose.Your health information is to be exchanged only with those involved in your direct care. This includes the medical staff at this office. The employees as medical staff of this office are not allowed to discuss your care outside of this office. Any breach of confidentiality is considered serious and possible grounds for dismissal.No health information can be used or exchanged with drug companies for research or marketing use without your rmation concerning mental health condition is never sent without your consent. Also no information regarding alcohol or drug treatment, abortion or adoption, mental-health disorders, or HIC testing never leave this office in a record transfer without your specific consent and only if the transfer of that information is needed in the medical record being sent.In every office someone is designated to insure the patient’s privacy is protected. To doubly ensure your privacy, I personally give the go-ahead before any record is sent. I review the medical record for accuracy, compliance, completion, and legibility before it leaves the rmation from genetic or Genomic tests will not be included with other information and will not be released without specific consent. It is kept filled separately from the rest of your record.We work hard to ensure your confidentiality. Comments and questions may be given to me. Thank you.Elizabeth Markovich, A. R. N. P.Registration and DemographicsMr Mrs Dr Fr Name (as on insurance card)___________________________________________Nickname or preferred name____________________________________ Sex: M___ F____Date of Birth: __________________ Social Security Number: ___________________________Address: __________________________________City___________State_____Zip _________Phone: Home:_________________ Work:_______________ Mobile: ____________________Email________________________ What’s the best way to reach you?___________________Can we leave a message about routine test results, Etc? YES____________ NO__________ Marital Status: S M W D Spouse Name ________________________ Date of birth _____________________ Emergency Contact: ___________________________________Employer (Self or spouse) ____________________________________Religion or Spiritual affiliation ____________________________________How did you hear about us? (Please be specific as possible) __________________________Usual primary care provider (if any) __________________________________ Pharmacy/location:_____________________________________________________Primary Insurance Company: _________________________________(a copy of the card is needed) If no card available – Member#_______________________Group#________________________Secondary insurance: _________________________________ Member#________________________ Group #__________________________ Phone number of Company: (________)______________________ Private Notice: I understand all my personal medical information will be kept strictly private I understand a separate form giving specific permission for release of personal medical information will be required to send for previous records or share information other than relevant information for a specific referral medical for specialty services. I have seen or been offered the complete statement about my privacy rights.Signed_____________________________________________________________General Permission to Treat: I hereby authorize release of any medical records or information necessary to process a claim to Medicare, Blue Cross or other insurance carrier. I authorize payment of medical benefits to N. Elizabeth Markovich, ARNP/ Integrative Healthcare, Inc. for services rendered. I generally authorize treatment and have received information about the practice.Signed___________________________________________________________Annual Health HistoryName___________________________ Date of Birth _______________ Todays Date _________________Past Medical History□ Allergies□ Anemia□ Arthritis□ Bleeding disorder□ Blood pressure problems□ Bronchitis/Emphysema□ Cancer (type)________________________□ Chronic fatigue □ Chronic infection □ Depression□ Diabetes□ Diverticular diseaseReactions to food/additives? ________________________________________________□ Drug/alcohol problem□ Eating disorder□ Elevated cholesterol□ Epilepsy/seizure□ Fibromyalgia□ Gall bladder trouble□ Glaucoma□ Gout□ Hashimoto's thyroiditis□ Heart disease□ Hepatitis□ Irritable bowel syndrome□ Kidney or bladder disease□ Learning disabilities□ Liver disease□ Mental illness□ Migraine headaches□ Neurological problems□ Osteoporosis/osteopenia□ Pneumonia□ Reflux heart burn□ Shingles□ Skin problems□ Sleep problems□ Stomach ulcer□ Thyroid trouble□ Tooth/dentistry problem□ Varicose veinsDo you have Hormone Symptoms? ______ Please ask for the Hormone ChecklistWomen Only□ Abnormal MammogramDate of last Mammogram ________________________□ Abnormal Pap SmearDate of last Pap Smear __________________________□ EndometriosisDate of last menstrual cycle ______________________□ Fibrocystic breastsInterval of time between cycle ____________________ days□ Uterine FibroidsLength of cycle _______________________________ days□ Hot Flashes Number of pregnancies __________________________□ Menstrual IrregulartiesC-Section – yes/no? _____________________________□ Pelvic InfectionBirth control used – yes/no? ______________________□ Premenstrual Syndrome (PMS)Any recent changes in normal menstrual flow? (heavier, scanty, □ Vaginal Itch or dischargelarge clots,)___________________________________□ Vaginal Infections______________________________________________□ Polycystic OvariesMen Only□ Erectile Dysfunction□ Testicle lump or mass□ Prostate Cancer□ urination problems□ other ______________________________________________Birth to Early HistoryComplications during birth? __________________Early childhood illnesses? ___________________Date of last physical exam_________ Practitioner Name____________________________________Laboratory and other tests performed in the last 1-2 years? (e.g., stool analysis, blood and urine chemistries, PSA, colonoscopy, HIV test, etc.) ___________________________________________________________________________________Name__________________________ Date of Birth ____________ Todays Date _________________All hospitalizations, surgeries, severe injuries: Please list all complications (if any) and dates:YearSurgery, Illness, InjuryOutcome_____ _______________________________________________________ ___________________________________ _______________________________________________________ ___________________________________ _______________________________________________________ ______________________________Do you wear: Contact lenses/glasses? ______ Dentures? _______ Other ______________________________________Do you have Medical devices, prosthetics, implants? ______What are they? ___________________________________Social HistoryWho do you live with? (People/pets?) __________________________________________________________________How do you spend most days? (Occupation, hobbies) ______________________________________________________Is your job associated with potentially harmful chemicals (e.g. pesticides, radioactivity, solvents) or health and/or life threatening activities (e.g. fireman, farmer, miner)? If yes, explain: ____________________________________________________Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest): 12345678910Identify the major cause of stress (changes in job, work, residence, finances or legal problems): ___________________________________________________________________________________________________________________Have you had weight loss or gain of 10 pounds or more in the last year? Yes/No? ______________________________Exercise□ Just up around house□ Run, jog, jump rope□ Swim□ Walk□ Weight lifting□ Yoga□ gardening□ other _________________________Exercise frequency□ 1-2 days per week□ 3-4 days per week□ 5-7 days per weekHealth Habits□ Alcohol drinks/day ___________________□ Caffeinated drinks/day ________________□ Tobacco use/day _____________________□ Other or recreational drug use _____________________________________ Nutrition & Diet□ Vegan□ Vegetarian□ Mixed food diet (animal & vegetable)□ Food rotation/combing□ Salt restriction□ Starch/carbohydrate restriction□ Total calorie/portion restriction□ Specific food restriction ________________□ Other special diet ______________________ Your Health Goals: □ Be free of pain□ Be thinner□ Have more energy□ Feel more motivated□ Get less colds and flu□ Get rid of allergies□ Reduce use and dependence on medications□ Sleep better□ Think more clearly and be more focusedFamily Health History(Please Note Familial Relationship)□ Alcoholism□ Alzheimer’s disease□ Arthritis□ Asthma□ Depression□ Diabetes□ Heart disease□ High blood pressure□ Mental illness□ Migraine headaches□ Neurological disorders□ Osteoporosis□ Stroke□ Other genetic disorder _________ ________________□ Cancer Type?___________□ Other ________________________________Do you have Allergies? □ NoneTo Medications? _______________________________________________________________________To Foods/Environment? _________________________________________________________________HEALTH INFORMATION RELEASEPatient NAME ________________________________________Date of Birth ____________________SENDING FOR RECORDS FROM OTHER PROVIDER;I permit the release my own health and medical information TO Elizabeth Markovich, N.P. and Integrative Healthcare FROM: _____________________________________________________________________________ (name of doctor, hospital, nurse practitioner or other health care provider). ________________ fax/phoneI permit the release of (check one or more): ________ Lab tests from the last year* ________Special tests for 5+ years (MRI's etc)* ________ Hospital admission and discharge summaries*________ ALL records for the last year ________ Most recent history and physical* *these are all we usually need________ Mental Health, HIV/AIDS information and testing* SIGNED_____________________________________________________________________________________________________________________________________________________________ SENDING RECORDS FROM IHC; I permit the release my own health and medical information FROM Integrative Healthcare, Elizabeth Markovich, N.P. TO: ________________________________________________________________________________ (name of doctor, hospital, nurse practitioner or other health care provider). ______________phone/fax I permit the release of (check one or more): ________ Lab tests from the last year ________ Most recent history, physical, office visit notes for the last year________ Special tests from the last year ________ Mental Health, HIV /AIDS information________ ALL recordsSIGNED _______________________________________Reason for requesting records _____________________________________________________PERSONAL COMMUNICATION; I request Elizabeth Markovich, NP be allowed to talk with and otherwise communicate with ___________________________________________________________ (friend, relative, counselor, other practitioner, etc.) GET HOSPITAL RECORDS IF NEEDED IN FUTURE; In case I am treated at the hospital sometime in the future (either Tallahassee Memorial or Capital Regional Medical Center) at the Emergency Room or admitted to the hospital I want Elizabeth Markovich, NP and Integrative Healthcare to be able to get my records including Admission and Discharge Summaries, and all tests done. SIGNED________________________________________Integrative Healthcare, Inc. Elizabeth Markovich, ARNP, 1630 Riggins Rd. Tallahassee, FL 32308p: (850) 878-4434 f: (850) 878-4423 Medical Symptoms Questionnaire (MSQ)Medical Symptoms Questionnaire (MSQ)Patient Name Date Rate each of the following symptoms based upon your typical health profile for the past 14 days.Point Scale0 – Never or almost never have the symptom 1 – Occasionally have it, effect is not severe 2 – Occasionally have it, effect is severe– Frequently have it, effect is not severe– Frequently have it, effect is severe457200-6350HEAD00HEAD Headaches Faintness Dizziness InsomniaTotal EYES Watery or itchy eyes Swollen, reddened or sticky eyelids Bags or dark circles under eyes Blurred or tunnel visionTotal (Does not include near or far-sightedness)EARS Itchy ears Earaches, ear infections Drainage from ear Ringing in ears, hearing lossTotal NOSE Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formationTotal MOUTH/THROAT Chronic coughing Gagging, frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen or discolored tongue, gums, lips Canker soresTotal SKIN Acne Hives, rashes, dry skin Hair loss Flushing, hot flashes Excessive sweatingTotal HEART Irregular or skipped heartbeat Rapid or pounding heartbeat Chest painTotal 45720013271500Version 2 MEDICAL SYMPTOMS QUESTIONNAIRE (MSQ)172656511366500 Chest congestion457200-227330LUNGS00LUNGS Asthma, bronchitis Shortness of breath Difficulty breathingTotal 172656517018000 Nausea, vomiting459105-213995DIGESTIVE TRACT00DIGESTIVE TRACT Diarrhea Constipation Bloated feeling Belching, passing gas Heartburn Intestinal/stomach painTotal 172656516827500 Pain or aches in joints459105-215900JOINTS/MUSCLE00JOINTS/MUSCLE Arthritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tirednessTotal 172656516764000 Binge eating/drinking459105-217170WEIGHT00WEIGHT Craving certain foods Excessive weight Compulsive eating Water retention UnderweightTotal 172656516637000 Fatigue, sluggishness459105-218440ENERGY/ACTIVITY00ENERGY/ACTIVITY Apathy, lethargy Hyperactivity RestlessnessTotal 172656517653000 Poor memory459105-207645MIND00MIND Confusion, poor comprehension Poor concentration Poor physical coordination Difficulty in making decisions Stuttering or stammering Slurred speech Learning disabilitiesTotal 172656517208500 Mood swings459105-212090EMOTIONS00EMOTIONS Anxiety, fear, nervousness Anger, irritability, aggressiveness DepressionTotal 172656516827500 Frequent illness459105-216535OTHER00OTHER Frequent or urgent urination45720064262000 Genital itch or dischargeTotal Grand Total ................
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