patient name: date of birth: -...
TRANSCRIPT
Patient Name: ____________________________________________ Date of Birth: __________________
Review of Systems – Please Circle any Symptoms that CURRENTLY Apply to you (past/present)
Constitution Eyes Endocrine Allergy/Immunology
Activity Change Eye Discharge Cold Intolerance Environmental Allergies
Appetite Change Eye Itching Heat Intolerance Food Allergies
Chills Eye Pain Very Thirsty Impaired Immune System
Sweating Eye Redness Excessive Hunger
Fatigue Light Sensitivity Urinate Large Volumes
Fever Visual Disturbance
Unexpected Weight Change
HENT Respiratory GU Neurological
Facial Swelling Apnea Difficulty Urinating Dizziness
Neck Swelling Chest Tightness Painful Intercourse Facial Asymmetry
Neck Stiffness Choking Painful Urination Headaches
Ear Discharge Cough Bedwetting Light-Headedness
Hearing Loss Shortness of Breath Flank Pain Numbness
Ear Pain Vibration of Chest Frequent Urination Seizures
Ringing in Ears Wheezing Genital Sore Speech Difficulty
Nosebleeds Blood in Urine Loss of Consciousness
Congestion Cardiovascular Menstrual Problems Tremors
Runny Nose Chest Pain Penile Discharge Weakness
Postnasal Drip Leg Swelling Penile Pain
Sneezing Palpitations Penile Swelling Hematologic
Sinus Pressure Pelvic Pain Enlarged Lymph Nodes
Dental Problem GI Scrotal Swelling Bruises/Bleeds Easily
Drooling Swelling of Abdomen Testicular Pain
Mouth Sores Abdomen Pain Urgent Urination Psychiatric
Sore Throat Anal Bleeding Urine Decreased Agitation
Trouble Swallowing Blood in Stool Vaginal Bleeding Behavior Problems
Constipation Vaginal Discharge Confusion
Skin Diarrhea Vaginal Pain Decreased Concentration
Color Change Nausea Depression
Pale Rectal Pain Musculoskeletal Hallucinations
Rash Vomiting Joint Pain Hyperactive
Wound Back Pain Nervous/Anxious
Problems Walking Self-Injury
Joint Swelling Sleep Disturbance
Muscle Pain Suicidal Ideas
List ALL Providers/Specialist seen:
WHO WHEN WHERE
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PLEASE CHECK THE CORRECT OFFICE
45 Amberwood Parkway, Ashland, OH 44805 558 S.Trimble Rd, Mansfield, OH 44906
770 Balgreen Dr. Ste 203, Mansfield, OH 44906 248 Blymyer Ave, Mansfield, OH 44903
1020 Cricket Ln, Mansfield, OH 44906 375 W. Main St., Lexington, OH 44904
175 W. 4th Street, Mansfield, OH 44906
NAME: ___________________________PREFERRED NAME:______________ DOB: _________/___________/_______
ALIASES: _____________________________________________________ SSN: ________-___________-________
ADDRESS: _____________________________________________________ TELEPHONE NO: ______-_____-_______
GUARDIAN OR RESPONSIBLE PERSON: _______________________________________CELL NO: ______-_____-_______
ALLOWED TO LEAVE VOICEMAIL MESSAGE ON TELEPHONE? YES OR NO
EMAIL: __________________________________________________ LANGUAGE:________________________
RACE: ________________ ETHNICITY: HISPANIC/NOT HISPANIC RELIGIOUS AFFILIATIONS: __________
PLEASE CIRCLE THE APPROPRIATE ANSWER:
GENDER IDENTITY: MALE FEMALE TRANSGENDER MALE TRANSGENDER FEMALE SOMETHING ELSE
SEXUAL STATUS: STRAIGHT HETEROSEXUAL LESBIAN GAY HOMOSEXUAL BISEXUAL OTHER I DON’T KNOW
MARITAL STATUS: SINGLE MARRIED DIVORCED SEPERATED WIDOWED CIVIL UNION LIFE PARTNER POLYGAMUS
SEXUAL ACTIVITY: NOT CURRENTLY YES NO PARTNERS: MALE FEMALE BOTH
PREFERRED TO BE REFERRED TO AS: MALE FEMALE OTHER: ________________________
EMERGENCY CONTACT: ___________________________DOB:______________ TELEPHONE NO: ______-______-________
RELATIONSHIP TO PATIENT: ________________________________
CONTACT ALLOWED TO HAVE MEDICAL/BILLING INFORMATION? YES OR NO
ANY ADDITIONAL PEOPLE ALLOWED TO HAVE MEDICAL/BILLING INFORMATION:
NAME:__________________________DOB:____________TELEPHONE: _______________RELATION___________________
PLEASE BRING COPY WITH YOU TO OFFICE VISIT
NONE DNR (Do Not Resuscitate) LIVING WILL DO NOT PLACE ON LIFE SUPPORT HEALTHCARE PROXY DURABLE POWER OF ATTORNEY
HAVE YOU SERVED IN THE MILITARY? _____________ WHICH BRANCH? __________________________________
EMPLOYER NAME/ADDRESS: _____________________________________________________________________________
STATUS: FULL TIME PART TIME SEASONAL RETIRED STUDENT
WORK TELEPHONE NO: _______-________-_________ OCCUPATION: ______________________________________
Primary Insurance:___________________________________ Policy # _______________________________________ GROUP #__________________________________________ SUBSCRIBER NAME__________________________________ DOB_____________ RELATIONSHIP TO PT________________________________________________________________
SMOKING STATUS: CURRENT EVERY DAY CURRENT SOME DAY HEAVY SMOKER LIGHT SMOKER FORMER SMOKER
NEVER SMOKED PASSIVE SMOKE EXPOSURE-NEVER SMOKED UNKNOWN
TYPES: E-CIGARETTE VAPE CIGARETTECIGAR PIPE CHEW SNUFF
START DATE: _____________________ QUIT DATE: __________________ READY TO QUIT: ______________ COUNSELING GIVEN: _______________
YES NO YES NO
TYPE: ___________________________________________ TYPE: ______________________________________________
COMMENTS: ______________________________________ COMMENTS: ________________________________________
HOW OFTEN: _____________________________________ HOW OFTEN: ________________________________________
NKDA (No known drug allergies) ENVIRONMENTAL SEASONAL
YES (PLEASE LIST)__________________________________________________________________________________________
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DO YOU USE CAFFEINE? YES OR NO AMOUNT OF CAFFEINE PER DAY: __________________________________
CAFFEINE TYPE: COFFEE CHOCOLATE ENERGY DRINK TEA OTHER
DAILY ACTIIVITY LEVEL: MODERATE SEDENTARY VIGOROUS
WHAT TYPE OF EXERCISE DO YOU DO? ________________________________________________________________________
NUMBER OF TIMES PER WEEK: _________________________ NUMBER OF HOURS EXERCISE PER WEEK: __________________
TYPE OF DIET: 1600 CALORIE 1800 CALORIE 2000 CALORIE DIABETIC GLUTEN FREE HEALTHY
HIGH CALORIE HIGH FAT HIGH SALT HIGH ROUGHAGE JUNK FOOD LOW FAT
LOW RESIDUE LOW SALT NO RED MEAT VEGAN VEGATARIAN
PHARMACY NAME: ______________________________________ PHARMACY TELEPHONE: _______-_______-_______
PHARMACY ADDRESS: __________________________________________________________________________________
MEDICATION NAME (BRAND OR GENERIC NAME) MEDICATION STRENGTH/DOSAGE MEDICATION DIRECTIONS
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ANEMIA CHF GERD KIDNEY DISEASE STROKE
ANXIETY CLOTTING DISORDER GLAUCOMA MENINGITIS SUBSTANCE ABUSE
ARTHRITIS COPD HEART MURMUR M.I THYROID DISEASE
ASTHMA DEPRESSION HEPATITIS OSTEOPOROSIS TUBERCULOSIS
CANCER DIABETES HIV/AIDS SEIZURES ULCERS
CATARACTS EMPHYSEMA HYPERTENSION SICKLE CELL ANEMIA
DIAGNOSIS/ DISEASE DATE DIAGNOSED MANAGEMENT OF DIAGNOSIS/DISEASE
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TYPE OF SURGERY DATE OF SURGERY DOCTOR AND FACILITY SURGERY WAS DONE
AT
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BABY #1 DATE OF BIRTH___/___/_____ SEX: MALE OR FEMALE DELIVERY TYPE: _____________________
MISCARRIED: YES OR NO WEIGHT _______LBS LENGTH __________INCHES
BABY #2 DATE OF BIRTH___/___/_____ SEX: MALE OR FEMALE DELIVERY TYPE: _____________________
MISCARRIED: YES OR NO WEIGHT _______LBS LENGTH __________INCHES
BABY #3 DATE OF BIRTH___/___/_____ SEX: MALE OR FEMALE DELIVERY TYPE: _____________________
MISCARRIED: YES OR NO WEIGHT _______LBS LENGTH __________INCHES
BABY #4 DATE OF BIRTH___/___/_____ SEX: MALE OR FEMALE DELIVERY TYPE: _____________________
MISCARRIED: YES OR NO WEIGHT _______LBS LENGTH __________INCHES
PLACE A NUMBER OF PREGNANCIES/DELIVERIES FOR THOSE THAT APPLY:
_______ FULL TERM DELIVERY __________PREMATURE DELIVERY __________CESAREAN DELIVERY
_______VAGINAL DELIVERY (NOT INDUCED) __________VAGINAL DELIVERY (INDUCED) __________LIVING BIRTHS
_______MULTIPLE BIRTHS (TWINS, ETC) ___________ABORTION ___________MISCARRIAGE
AGE OF FIRST MENSTRAL PERIOD: _____________ AGE AT MENOPAUSE: __________________
AGE OF FIRST BIRTH: _______________________ DATE OF LAST PAP: ___________________
DATE OF LAST MENSTRUAL PERIOD: ___________ HORMONE REPLACEMENT THERAPY: YES OR NO
DATE OF LAST MAMMOGRAM: ________________
NAME OF PRIMARY CARE GIVER: ______________________________________________________________
RELATIONSHIP TO PRIMARY CARE GIVER: MOTHER FATHER FOSTER PARENT GRANDPARENT STEP PARENT OTHER
HOW MANY DAYS A WEEK DOES PATIENT SPEND WITH PRIMARY CARE GIVER: _____________________________
SMOKE EXPOSURE: SMOKER AT HOME OUTSIDE SMOKE ONLY NO SMOKE EXPOSURE
HAND DOMINANCE: LEFT RIGHT AMBIDEXTROUS (BOTH HANDS)
DOES PATIENT ATTEND DAY CARE? _________________________ HOW MANY DAYS A WEEK? ___________________
CAR RESTRAINT: CAR SEAT REAR FACE CAR SEAT FRONT FACE BOOSTER SEAT BELT NONE
NUMBER OF SIBLINGS: ________________ BIRTH ORDER: FIRST SECOND THIRD FOURTH FIFTH
HOW MANY HOURS DAILY DOES THE PATIENT: WATCH TV ________ EXERCISE/PLAY SPORTS ________ VIDEO GAME________
CIRCLE ALL THAT APPLIES: TAKES NAPS SLEEPS WITH PARENTS SLEEPS THROUGH THE NIGHT
SLEEPS MINIMUM OF 8.5 HOURS NIGHTLY NIGHTMARES/SLEEP PROBLEMS
LEARNING DISABILITY SPECIAL NEEDS GIFTED PROGRAM LIKES SCHOOL
TRUANCY COLLEGE PREP H.S. GRADUATE
BELOW AVERAGE GRADES AT AVERAGE GRADES ABOVE AVERAGE GRADES
SCREENING MEASURES PROVIDER/LOCATION DATE
Tdap/TD Vaccine
Pneumonia Vaccine
Shingles Vaccine
Colonoscopy/Cologuard
Mammogram
Dexa/Bone Density
PAP/HPV
Low Dose Lung CT
Diabetic Foot/Eye Exam
A1C
Hep C Screening
STATUS PROBLEM AGE ONSET COMMENT
MOTHER
FATHER
SISTER
BROTHER
MGM
PGM
PGF
Adopted Family History Unknown