Name: ______
Date of Birth:______
History and Intake Form
Past Medical History: (please circle all that apply)
Anxiety
Arthritis
Artificial joints
Asthma
Atrial fibrillation
BPH
Bone Marrow Transplantation
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes
End Stage Renal Disease
GERD
Hearing Loss
Hepatitis
Hypertension
HIV/AIDS
Hypercholesterolemia
Hyperthyroidism
Hypothyroidism
Leukemia
Lung Cancer
Lymphoma
Pacemaker
Prostate Cancer
Radiation Treatment
Seizures
Stroke
Valve Replacement
None
Other ______
Past Surgical History: (please circle all that apply)
Appendix Removed
Bladder Removed
Mastectomy (Right, Left, Bilateral)
Lumpectomy (Right, Left, Bilateral)
Breast Biopsy (Right, Left, Bilateral)
Breast Reduction
Breast Implants
Colectomy: Colon Cancer Resection
Colectomy: Diverticulitis
Colectomy: IBD
Gallbladder Removed
Coronary Artery Bypass
PTCA
Mechanical Valve Replacement
Biological Valve Replacement
Heart Transplant
Joint Replacement, Knee (Right, Left, Bilateral)
Joint Replacement, Hip (Right, Left, Bilateral)
Joint Replacement within last 2 years
Kidney Biopsy
Kidney Removed (Right, Left)
Kidney Stone Removal
Kidney Transplant
Ovaries Removed: Endometriosis
Ovaries Removed: Cyst
Ovaries Removed: Ovarian Cancer
Prostate Removed: Prostate Cancer
Prostate Biopsy
TURP
Skin Biopsy
Basal Cell Cancer Surgery
Squamous Cell Carcinoma Surgery
Melanoma Surgery
Spleen Removed
Testicles Removed (Right, Left, Bilateral)
Hysterectomy: Fibroids
Hysterectomy: Uterine Cancer
None
Other ______
Name: ______
Date of Birth:______
Skin Disease History: (please circle all that apply)
Acne
Actinic Keratoses
Asthma
Basal Cell Skin Cancer
Blistering Sunburns
Dry Skin
Eczema
Flaking or Itchy Scalp
Hay Fever/Allergies
Melanoma
Poison Ivy
Precancerous Moles
Psoriasis
Squamous Cell Skin Cancer
None
Other ______
Do you wear Sunscreen? YesNo
If yes, what SPF? ______
Do you tan in a tanning salon? YesNo
Do you have a family history of Melanoma?YesNo
If yes, which relative(s)? ______
Any other family history: ______
Medications: (Please enter all current medications)
______
Allergies: (Please enter all allergies)
______
Preferred Language: English ______Other: ______
Some diseases are more prevalent in certain racial and ethnic groups, therefore we would appreciate it if you would specify your race and ethnicity.
Race (please check or circle):
_____ Caucasian
_____ African American
_____ American Indian
_____ Asian
____ Other (please specify): ______
Ethnicity: ______Hispanic or Latino ______Not Hispanic or Latino
Name: ______
Date of Birth:______
Social History: (Please circle all that apply)
Cigarette Smoking:
Never smoked
Quit: former smoker
Smokes less than daily
Smokes daily
Sexual History:
Not sexually active
Sexually active with one partner
Sexually active with more than one partner
Same sex partner
Illicit Drug Use:
Drug Use
IV Drug Use
Alcohol Use:
Alcohol: none
Alcohol: less than 1 drink a day
Alcohol: 1-2 drinks a day
Alcohol: 3 or more drinks a day
Safety:
I feel safe at home.
I do not feel safe at home.
Other______
None
Name: ______
Date of Birth:______
Are you currently experiencing any of the following?
(please check yes or no for the following)
Symptom / Yes / NoAllergy to lidocaine
Rapid heart beat with epinephrine
Allergy to topical ointments
Allergy to adhesive
Blood thinners
Artificial joints within past two years
Artificial heart valve
Premedication prior to procedures
Problems with bleeding
Problems with healing
Problems with scarring (hypertrophic or keloid)
Yeast infection with antibiotics
GI upset with antibiotics
Thyroid problems
Joint aches
Muscle weakness
Neck stiffness
Sore throat
Fevers or chills
Night sweats
Unintentional weight loss
Abdominal pain
Bloody stool
Bloody urine
Other Symptoms: ______
Name: ______
Date of Birth:______
Alerts: Are you currently experiencing any of the following?
(please check yes or no for the following)
Alert / Yes / NoChest pain
Pace maker
defibrillator
Shortness of breath
wheezing
cough
headache
Blurry vision
seizures
depression
anxiety
immunosuppression
Hay fever
rash
Changing mole
Pregnancy or planning a pregnancy
Any other health concern we should know about
Other Symptoms: ______
Name: ______
Date of Birth: ______
Pharmacy and Doctor Information
Pharmacy
Name: ______
Address: ______
______
Telephone Number: ______
Primary Care Physician
Name: ______
Address: ______
______
Telephone Number: ______
Please list other physicians to whom we need to send records:
______
______
______
______
Theta S. Pattison, MD
2508 Western Avenue
Altamont, NY 12009
Telephone: 518-690-0177
Fax: 518-690-0169
HIPAA Communication Authorization
Permission to communicate protected health information
HIPAA limits healthcare organizations as to who they may communicate with regarding your care and how they may communicate. In order to help us communicate about your care as you want and with whomever you want, we ask that you complete this form.
Please provide us with the names of those individuals who are involved with your care and with whom we may share your protected health information. I authorizeTheta S. Pattison, MD and employees, using their best judgment, to discuss my healthcare and my protected health information with the following individuals in order to facilitate and coordinate my care:
______
Name of IndividualRelationship to PatientTelephone Number
______
Name of IndividualRelationship to PatientTelephone Number
______
Name of IndividualRelationship to PatientTelephone Number
______
Name of IndividualRelationship to PatientTelephone Number
We also would like to be able to leave telephone messages containing protected health care information for you, if you are willing to let us do so. I authorize Theta S. Pattison, MD and employees to leave messages containing protected healthcare information at the following telephone number(s): ______.
Patient’s Name (print): ______Date of Birth: ____/____/____
Signed: ______Date: ______
If Signed by someone other than the patient, please specify
your authority to act for patient: ______