Medical Information Database
Name: __________________________________________ Date: __________________ Reason for seeing doctor: ___________________________________________________ Referring Physician: _______________________________________________________ Were you seen in the Emergency Room? YES NO ___ Richland ___ Baptist ___ Lexington ___ Providence ___ Providence NE ___ Other Date of accident or injury: _______________ If not accident or injury, date the symptoms began: __________________ Current physician, pediatrician, or family doctor, if you have one: __________________ Previous Medical History
List all known allergies: ____________________________________________________ ________________________________________________________________________ Do you have a Latex Allergy/Sensitivity? YES NO List all medications you are taking and reason you are taking it (including Aspirin, Ibuprofen, Motrin, NSAID, Goody Powder, Vitamins, herbal Medication, etc.): _______ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ List any medications that you cannot take: _____________________________________ _______________________________________________________________________ Immunizations
Please indicate date (month and year) of last immunization. Tetanus Booster ____________
Patient Name: ____________________________________ Date: __________________
Current Medical Problems
Please “X” YES or NO YES NO
___ ___ Breast Disease ___ ___ Other, if any please explain: ________________________________________ Review of Systems
Please “X” YES or NO YES NO
Previous Hospitalizations
Date
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Patient Name: ____________________________________ Date: __________________ Past Surgical History
Date
Social History
Do you use tobacco products of any kind? YES / NO Amount / Frequency: __________ Do you drink alcohol? YES / NO Amount / Frequency: __________________________ Do you use illegal drugs? YES / NO Amount / Frequency: _______________________ Occupation: _____________________________________________________________ Living Situation: _________________________________________________________ Family History
Please “X” YES or NO and relationship YES NO Relationship
Reviewed and updated on _____________ By _________
Reviewed and updated on _____________ By _________
E. Comments from Survey Respondents In this appendix, we provide selected comments that we received from surveyrespondents. The comments have been organized according to the topicsdiscussed in Chapter 5 and are divided into three sections—general commentsfrom direct-care system prescribers; comments from direct-care prescribersspecifically in response to a question on changes they would make
Medical Information Database