Transcript new patient questionnaire

UNIVERSITY DIAGNOSTIC
TREATMENT CLINICS
Date:_________Patient Name:_____________________________________________________Date of Birth:_______________
Last
First
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Please list all prescriptions, vitamins, herbs, and over-the-counter medications that you are currently taking and/or bring your
Medications with you to your appointment.
(If additional space is needed please copy this page)
Medications
Strength
Dose
How many times a day
**Allergies**
Medication
(Include prescription, over –the-counter and /or vitamins)
Have you ever had an allergic reaction to:
What type of reaction did you have:
Describe reaction
Contrast Dye
Hives
Iodine
Shortness of breath
Shell Fish
Other: _________________
_________________________________________________________________________________________
**Pharmacy Information**
___________________________________________________
Pharmacy Name
(
) __________________________
Phone number
___________________________________________________________________________________________________
Address
City
State
Zip Code
UNIVERSITY DIAGNOSTIC
TREATMENT CLINICS
Date:_________Patient Name:_____________________________________________________Date of Birth:_______________
Last
First
Have you ever had any of the following symptoms or diseases?:
Seizures
Tuberculosis
Asthma
Heart Failure
Heart Murmur
Breast Mass/Cyst
Bleeding Disorder
Bladder Infections
Kidney Stones
Blood clots in legs
Cancer
Blood in stool
Diarrhea
Change in stools
Change in weight
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Thyroid Disease
Shortness of Breath
Heart Attack
Chest Pain
High Blood Pressure
Stomach/intestinal ulcers
Diabetes
Vaginal Infections
Arthritis
Hepatitis
Blood in Urine
Frequent urination
Constipation
Black tarry stools
Swelling in legs/feet
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Has anyone in your family ever had any of the following diseases? If yes, list their relationship to you:
Uterine Cancer: __________________________________________________________
Cervical Cancer: __________________________________________________________
Ovarian Cancer: __________________________________________________________
Breast Cancer: ___________________________________________________________
Colon Cancer: ____________________________________________________________
Prostate Cancer: __________________________________________________________
High blood pressure: _______________________________________________________
Diabetes: ________________________________________________________________
Is there anything else in your health history that you feel I should know?: ____________________________
______________________________________________________________________________________
List any surgeries, the date, and hospital where the surgery was performed:
Date:
Surgery Type:
Hospital:
Notes:
UNIVERSITY DIAGNOSTIC
TREATMENT CLINICS
Date:_________Patient Name:_____________________________________________________Date of Birth:_______________
Last
First
Review of Symptoms
General
___Weight loss/gain
___Energy Level
___Fatigue
___Poor Appetite
___Night Sweats
Digestion
___Nausea
___Heartburn
___Indigestion
___Vomitting
___Diarrhea
___Constipation
___Hemorrhoids
___Bleeding
___Black Stools
___Other
Gento-Urinary System
___Burning
___Dark or bloody urine
___Stones
___Infection
___Colonoscopy
___Constipation
Respirations
___Cough
___With sputum
___With blood
___Chest pain
___Wheezing
___Other
Cardiovascular
___Chest pain with effort
___Cholesterol
___Heart Problems
___Hypertension
___Shortness of Breath
___Heart Attack
___Stroke
___Angina
Eyes
___Blurred vision
___Double vision
___Cataracts
___Glaucoma
___Spots
___Other
Ear, Nose & Throat
___Poor hearing
___Ringing in ears
___Hearing Aid
___Nose Bleeds
___Stuffy Nose
___Sinusitis
___Difficulty Chewing Food
___Difficulty Swallowing
___Dentures
___Hoarseness
Skin
___Itching
___Rash
___Sores
___Other
Emotional Status
___Nervous
___Tearful
___Depressed
___Change in sleeping pattern
___Other
Pain
___Severity-1, 2, 3, 4, 5, 6, 7, 8, 9, 10
___Location____________________
___Duration____________________
___What makes it:
___Better______________________
___Worse_____________________
Women
___Irregular periods
___Missed periods
___Hot flashes
___Last pap smear
___Last mammogram
Men
___Prostate problems
___Last prostate exam
___Last PSA test
___How many times do you urinate at
night
___Other
Joints and Muscles
___Joint pain
___Back pain
___Swollen joints, where
_____________________
___Other
___________________________________________________________________________________________
Patient Signature
Date
Reviewed with patient by:
__________________________________________________________________________________________
Physician Signature
Date
UNIVERSITY DIAGNOSTIC
TREATMENT CLINICS
Date:_________Patient Name:_____________________________________________________Date of Birth:_______________
Last
First
PATIENT CONFIDENTIALITY QUESTIONAIRE
1. Please list the family members or other persons, if any, that we may inform about your
general medical condition and your diagnosis:
Name:__________________________
Name:__________________________
Phone:______________________________
Phone:______________________________
2. Please list the family members or significant other, if any, that we may inform about your
medical condition ONLY IN AN EMERGENCY:
Name:__________________________
Name:__________________________
Phone:______________________________
Phone:______________________________
3. Please print where you would prefer to have your billing statement and/or correspondence
from our office sent if other than your home address:
Address:________________________________________________________________
City:_______________________________State:_____________Zip Code:___________
4. Please print the name of the person (if other than self) and phone number where you would
like to receive phone calls concerning your appointments, labs, radiology results, or other
health information if other than your home phone number.
Name:___________________________ Number:________________________________
Can confidential messages (i.e. appointment reminders) be left on your telephone
answering machine?
Yes_______
No________
___________________________________________
Patient/Guardian Signature
_______________________
Date
UNIVERSITY DIAGNOSTIC
TREATMENT CLINICS
INDIVIDUALS YOU DO NOT WANT INVOLVED IN
YOUR CARE OR PAYMENT FOR YOUR CARE
Patient Name:______________________________________________________________________
Patient Acct.#:______________________________________________________________________
Date of Birth:_______________________________________________________________________
According to our Notice of Privacy Practices, we may release your health information, including
information about your condition to a family member or friend who is involved in your medical care or
who helps you pay for your car. If you would like us to refrain from releasing your health information to
a family member or friend, please list the name(s) of who you DO NOT want your private health
information released to on the lines below. Remember, in the future, if there are additions to this list,
please notify the University Cancer Diagnostic and Treatment Clinics staff. This authorization will
remain in effect until revoked by you in writing. Thank you.
Name:_____________________________________________________________________________
Name:_____________________________________________________________________________
Name:_____________________________________________________________________________
Name:_____________________________________________________________________________
_________________________________________________
Patient Signature
____________________
Date
UNIVERSITY DIAGNOSTIC
TREATMENT CLINICS
Dear Patient,
Welcome to University Cancer Diagnostic and Treatment Clinics. We appreciate the
opportunity to provide you with the highest quality care available. If you have any questions or
concerns, ask and we will do our best to give you a response as quickly as possible.
Also attached are:
• a Patient Confidentiality Questionaire for you to tell us who, if anyone, you would like to have
access to your confidential records
• a Medical History Questionaire for you to tell us about your past and present health
• and an Assignment of Benefits form for you to provide us information concerning issures
about financial responsibility of your services
Please review and complete all attached forms to the best of your ability and bring with you to
your appointment or hand in to front desk.
To avoid scheduling delays and ensure that we can correctly assess your condition, please
ask your referring physician to provide us with all necessary medical records, pathology
reports and insurance referral forms (if applicable) prior to your appointment.
Again, if at any time you have questions, concerns or problems let us know. We will make
every effort to address your situation in the most satisfactory manner as possible.
Sincerely,
University Cancer Diagnostic and Treatment Clinics
Beamer
12811 Beamer Rd
Houston, TX 77089
Pasadena
4135 Spencer Highway
Pasadena, TX 77504
North Houston
1900 North Loop West, #310
Houston, TX 77018
Houston Heights
2724 Yale St
Houston, TX 77008
Phone: 713-474-1414
Fax: 713-474-8477
Phone: 713-474-1414
Fax: 713-474-8477
Phone: 713-474-1414
Fax: 713-474-8477
Phone: 713-474-1414
Fax: 713-474-8477