Outpatient Medical History/screening Form

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Outpatient Medical History/Screening Form
Account#: ___________________________________
To be completed by the patient
Patient Name:_____________________________________
Spoken Language:________________________________
Emergency Contact:________________________________
Telephone # :____________________________________
Family Physician/Internist:____________________________
Telephone # :____________________________________
How can we improve the quality of your life?_____________________________________________________________________
Do you have any religious, cultural, or learning needs that we can accommodate to improve your experience?:
No
Yes
If yes, please explain: ____________________________________________________________________
Date of Injury:_______________________________________________________________________________________
Medical Information:
YES
NO
YES
NO
Hypertension (high blood pressure)
Skin Sensitivity
Hypotension (low blood pressure)
Diminished Sensation
Pacemaker
Alzheimers
Emphysema /Asthma
Shortness of Breath
Bleeding / Bruising (recent history)
Chest Pain /Angina /Heart Attack
History of diabetes
Urinary Urgency / Incontinence
Hypoglycemia
Are You Pregnant?
Cancer / Tumors / Growths
Have you had/have a Stroke
Active seizure disorder
Brain Injury
Osteoporosis
Multiple Sclerosis
Swelling Of Extremities
Spinal Cord Injury
Fractures
History of pressure sores
DATE:_________ AREA:________
Other_____________________________________
Are you in pain?
DATE:_________ AREA:________
Artificial Joints
Location of pain_____________________________
Light-Headedness / Dizziness
If you answered yes to any of the above:
Anxiety / Panic Attacks (recent)
Are you under the care of an
YES
NO
Depression(recent)
MD for these conditions?
Allergies: ___________________________________________________________________________________
_____________________________________________________________________________________________
Surgery(s) within last 3 months - Include Dates: ____________________________________________________
If you need information regarding Advanced Directives, please contact the site Admission/Office Assistant.
Advanced Directives are not honored in the Outpatient Setting.
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