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BSA - CT Surgery New Patient Questionnaire
1.
Patient's Information
Last Name
First Name
Middle Initial
Social Security Number
Date of Birth
Age
Gender (Male / Female)
Marital Status (Married / Divorced / Widowed / Single)
Mailing Address
City
State
Zip
Home Phone Number
Work Phone Number
Other Phone Number
Email Address
Employer
2.
Emergency Contact’s Information
Last Name
First Name
Middle Initial
Home Phone Number
Work Phone Number
Other Phone Number
Relationship to Patient
3.
Responsible Party’s Information (if different from patient)
Last Name
First Name
Middle Initial
Social Security Number
Date of Birth
Age
Gender (Male / Female)
Marital Status (Married / Divorced / Widowed / Single)
Mailing Address
City
State
Zip
Home Phone Number
Work Phone Number
Other Phone Number
Email Address
Employer
Referral Information
4.
Did another physician refer you to BSA Cardiothoracic Surgery?
Yes
No
Physician Name
5.
What is the name of your primary or family physician?
6.
Please write the name(s) of any physicians we should send your medical records to from your visit at BSA Cardiothoracic Surgery.
Workman’s Compensation
7.
Is your illness related to an on the job injury?
Yes
No
If yes, please complete an insurance information form.
8.
I authorize the release of any medical information necessary to process a claim on my behalf and request payment of any insurance benefits to BSA Amarillo Surgical group or myself. I consent for BSA Medical Group to obtain my medication prescription history and place my prescription orders through the electronic prescribing system.
Signature
Date
Medical History Information
9.
Why are you being seen at BSA Cardiothoracic Surgery?
10.
List any medications that you are currently taking. If you are being seen in the hospital, list medications prior to admission. Please include your over-the-counter medications, prescription medications, vitamins, minerals or herbal supplements.
11.
Are you allergic to any medications?
Yes
No
Please list the medication(s) and your reaction(s)
12.
List any other medical conditions and/or previous illnesses or disorders.
13.
List previous major injuries.
14.
List previous operations/surgeries.
15.
List any diagnostic testing you have received related to your current condition.
16.
(Females Only) At what age did you begin menstruating?
17.
(Females Only) Have you stopped menstruating?
Yes
No
18.
(Females Only) Do you have regular periods?
Yes
No
N/A
19.
Do you take female hormones?
Yes
No
20.
(Females Only) Do you have any family members with breast cancer?
Yes
No
If yes, please list if it was from your mother or father’s side and at what age they were diagnosed.
21.
(Females Only) Do you have any family members with ovarian cancer?
Yes
No
If yes, please list if it was from your mother or father’s side and at what age they were diagnosed.
22.
Is your mother living?
Yes
No
23.
Is your father living?
Yes
No
24.
How old is your mother, or how old was she when she passed?
25.
How old is your father, or how old was he when he passed?
26.
Please check all that apply for your father’s medical history:
Stroke
Diabetes
High Blood Pressure
Heart Disease
Tuberculosis
Alcoholism
Jaundice
Bleeder
Obesity
Gout
Asthma
Cancer
Mental Illness
27.
Please check all that apply for your father’s medical history:
Stroke
Diabetes
High Blood Pressure
Heart Disease
Tuberculosis
Alcoholism
Jaundice
Bleeder
Obesity
Gout
Asthma
Cancer
Mental Illness
28.
List out any sibling or children you have with their ages.
Do any of your siblings or children have the following?
29.
Stroke
Yes
No
If yes, please list which family member.
30.
Diabetes
Yes
No
If yes, please list which family member.
31.
High Blood Pressure
Yes
No
If yes, please list which family member.
32.
Heart Disease
Yes
No
If yes, please list which family member.
33.
Tuberculosis
Yes
No
If yes, please list which family member.
34.
Alcoholism
Yes
No
If yes, please list which family member.
35.
Jaundice
Yes
No
If yes, please list which family member.
36.
Bleeder
Yes
No
If yes, please list which family member.
37.
Obesity
Yes
No
If yes, please list which family member.
38.
Gout
Yes
No
If yes, please list which family member.
39.
Asthma
Yes
No
If yes, please list which family member.
40.
Cancer
Yes
No
If yes, please list which family member.
41.
Mental Illness
Yes
No
If yes, please list which family member.
42.
Have you ever used tobacco?
Yes
No
43.
If you have used tobacco, please check all types you have used.
Cigarettes
Cigar
Pipe
Chewing/Snuff
Smokeless
N/A
44.
How many years have you or did you use tobacco?
45.
Have you ever tried to quit using tobacco?
Yes
No
N/A
Successfully quit
If you've successfully quit, what year?
46.
Are you regularly exposed to secondhand smoke?
Yes
No
47.
Do you drink alcohol?
Yes
No
What kind of alcohol do you drink?
48.
How often do you drink alcohol?
Daily
Weekly
Socially
Occasionally
Rarely
Never
49.
Do you drink any of the following?
Coffee
Tea
Soda
N/A
50.
How often do you drink caffeine?
Daily
Weekly
Occasionally
Rarely
Never
51.
What is your highest level of education?
High School
Some College
Associates Degree
Bachelor Degree
Master Degree
Doctorate
52.
What is your occupation?
53.
Employer Name
54.
Do you exercise regularly?
Yes
No
What kind?
55.
Do you follow a special diet?
Yes
No
What kind?
56.
List other people who live in your home and their relationship to you.
Review of Systems
Constitutional
57.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Chills
Fatigue
Fever
Night sweats
Weight gain
Weight loss
Head/ Eyes/ Ears/ Throat
58.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Hearing loss
Sore throat
Visual changes
Respiratory
59.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Chronic cough
Cough
Known TB exposure
Shortness of Breath
Wheezing
Cardiovascular
60.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Chest pain
Claudication (Leg cramps)
Palpitations
Edema (Swelling of feet, ankles, or legs)
Dyspnea (Shortness of breath with exertion)
Orthopnea (Difficulty breathing when lying flat)
Vascular
61.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
DVT (Blood clots in legs)
Phlebitis (Varicose Veins)
Gastrointestinal
62.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Abdominal pain
Blood in stools
Change in stools
Constipation
Diarrhea
Heartburn
Loss of appetite
Nausea
Vomiting
Reproductive (FEMALE ONLY)
63.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Breast discharge
Breast lump
Irregular Menses
Genitourinary
64.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Dysuria (Difficulty Urinating)
Hematuria (Blood in Urine)
Frequent Urination
Urinary Incontinence
Urinary Retention
Nocturia (Awakening to Urinate)
Metabolic/Endocrine
65.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Brittle nails
Cold intolerance
Changes
Heat intolerance
Polydipsia (excessive thirst)
Neurological
66.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Extremity numbness
Extremity weakness
Headache
Memory loss
Seizures
Tremors
Psychiatric
67.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Anxiety
Depression
Insomnia
Integumentary:
68.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Hives
Itching
Mole changes
Rash
Skin lesion
Musculoskeletal
69.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Back pain
Joint pain
Muscle weakness
Neck pain
Hematologic/Lymphatic
70.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Easy bleeding
Easy bruising
Lymphadenopathy (Swollen glands)
Immunologic
71.
Please provide a
yes
next to each symptom below if you experience it, or please provide a
no
next to each symptom if you do not experience it.
Food allergies
Seasonal allergies
Current Progress,
0 of 90 answered
