| What is the name of the individual who needs doctor consultation? | _______________________________ |
| DOB: | _____________ |
| Date: | ____________________ |
| Marital Status: | |
|
Where is the patient now? Address: | ___________________________________ |
| City: | _______________________ |
| State: | ______ |
| Zip: | _____________ |
| Home Phone: | ______________________ |
| Work Phone: | __________________ |
| Cell Phone: | _______________________ |
| Emergency Contact Name: | ______________________________ |
| Emergency Contact Phone: | ____________________ |
| Race: |
American American Asian Asian Black/African American Native Hawaiian/Pacific Islander Other Race White Unknown |
|
Race:
American/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander Other Race White Unknown | |
| Preferred Method Of Communication: | Phone Mail E-mail Text |
| Email: | ____________________________________ |
| Primary Care Physician: | ________________________ |
| Phone: | __________________ |
| Fax: | ________________________ |
| Pharmacy Name: | ___________________________________ |
| Phone: | __________________ |
| Fax: | ___________________ |
|
Reason for Visit: What is the reason for your visit: | Annual exam Obstetric first visit Gyn Problem |
| If you are here for a problem what are your concerns? ____________ Health Maintenance Screening Tests: | |
| Personal Medical History: |
Check if you had any of these medical problems in the past. Major illness Yes Major Illness Yes Anemia Hepatitis ?A ?B ?C Anxiety High blood Pressure Arthritis/Joint Pain High Cholesterol Asthma Hypothyroid Blood clot/DVT Hyperthyroid Blood Transfusions Interstitial Cystitis Breast Cancer IBS (irritable bowel syndrome) Cancer- list type: Jaundice Chronic Lung Disease Migraines Depression Osteopenia Diabetes Type1 Osteoporosis Diabetes Type 2 Ovarian Cancer Fibroids Seizures Fracture Sexually Transmitted Disease GERD Stroke Heart Disease |
| Other: | ______________________________________ |
|
Life Style: Please check off answer and give detail if it applies: Have you been a victim of abuse or domestic violence? ? Yes ? No Do you feel safe at home? ? Yes ? No Do you live alone? ? Yes ? No Do you perform self -breast exam? ? Yes ? No Do you drink milk or consume dairy products daily? ? Yes ? No Do you take calcium tablets? ? Yes ? No Do you exercise? ? Yes ? No If yes, frequency - how many times a week? _____________ Are you satisfied with your weight? ? Yes ? No Please add any additional information: ______________________________________ | |
| AUTHORIZATION AND RELEASE: I hereby certify that I have completed the above information to the best of my knowledge. I authorize, consent, request, and agree to actively participate in such services as routine assessments, the performance of diagnostic tests and procedures, care and treatment as self-referred or as ordered by my physician, his/her assistant or designees. _________________________ | |
| Signature Date | |
| Please mail or fax your completed form to our office prior to your appointment. If you cannot return your form prior to your appointment, you must arrive 30 minutes early so we can enter your information into the computer. Thank you for your attention and cooperation. | |
| http://www.qureshiuniversity.org/patientprofile.html |