Johns Hopkins Hospital
Johns Hopkins Community Physicians
Johns Hopkins Bayview
Other:
05-480171000011
Neurosurgery New Patient History Questionnaire
Patient Identification Information
Welcome to the Department of Neurosurgery at Johns Hopkins! We ask that you take some time to complete this questionnaire to the best of your knowledge. This questionnaire will allow the doctor to get to know more about you and your medical condition. Please complete this form before your visit, and bring it with you the day of your appointment. Also bring your insurance card, driver's license or identification card, reports of previous neurological and neurosurgical testing consultations, and reports of significant medical problems. Full Name___________________________________________DOB____________________Age____________ Address:___________________________________________________________________________________ Email_____________________________________________________________________________________ Phone Numbers: (H)____________________ (W)_____________________ (C)_________________________ Emergency Contact:________________________________________ Phone #__________________________
REFERRING PHYSICIAN INFORMATION Physician Name __________________________________________Specialty: __________________________ Address___________________________________________________________________________________ Phone ____________________________________ Fax Number: ____________________________________ Is there anyone else who should receive a copy of the clinic report? (i.e. Primary care physician) Physician Name __________________________________________ Specialty: __________________________ Address ___________________________________________________________________________________ Phone ___________________________________ Fax Number ______________________________________
PRESENT ILLNESS 1. What is the reason for your visit today? _______________________________________________________
2. What symptoms are you currently experiencing? 3. How long do the symptoms last? ______________How often do they occur? _________________________ 4. How severe are the symptoms on a scale of 0(no pain) 10(worst imaginable)?___ How severe is the pain?___ 5. Does anything make the problem better?
Yes
No Explain: _________________________________
6. Does anything make the problem worse?
Yes
No Explain: _________________________________
7. Have you had treatment for the problem?
Yes
No Explain:_________________________________
05-480171000011 PLUE (1/2011)
1 of 4
Johns Hopkins Hospital
Johns Hopkins Community Physicians
Johns Hopkins Bayview
Other:
05-480171000011
Neurosurgery New Patient History Questionnaire
Patient Identification Information
PAST MEDICAL HISTORY Please list all operations you have had in the past with approximate dates. (Example: Colectomy March 2010; Lumpectomy June 1996, etc.) _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Please list all current medical problems and major illness you have had with approximate dates: (Example: Diabetes, Diagnosed April 2004, High Blood Pressure, Diagnosed 1995, etc.) _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Have you ever had a blood transfusion or received blood products?
Yes
No
Have you had any problems with anesthesia?
Yes
No
If yes, please explain: ________________________________________________________________________ Are you:
Left handed
Right handed
Ambidextrous
Do you take aspirin, any medicines that contain aspirin, Ibuprofen, Advil, or Motrin?
Yes
No
Do you take any blood thinners such as Plavix, Coumadin, or Lovenox?
Yes
No
If yes, please list last date taken________________________________________________________________ Please list any drug allergies:
Please list any food allergies: 05-480171000011 PLUE (1/2011)
2 of 4
Johns Hopkins Hospital
Johns Hopkins Community Physicians
Johns Hopkins Bayview
Other:
05-480171000011
Neurosurgery New Patient History Questionnaire
Patient Identification Information
REVIEW OF SYSTEMS Please check the medical condition(s) below which apply to you either now or in the past. Cardiovascular Y N Hemilymphatic/ Ulcer Chest pain/pressure Y N Y N Endocrine Vomiting Y N Anemia Fainting Y N Blood disorder Heart attack Skin Y N Birth marks Y N Circulatory problems Heart defect Y N Y N Psoriasis Diabetes Heart murmur Y N Y N Skin rashes Dry eyes/mouth High blood pressure Y N Y N Melanoma Endocrine disorder Low blood pressure Y N Low blood sugar Leg Swelling Respiratory Lymph node swelling Asthma Y N Constitutional Hepatitis Altered taste/smell Y N Y N Bronchitis HIV/AIDS Y N Y N Cancer Chronic cough Pituitary disorder Y N Y N Change in appetite COPD Sickle cell disease Y N Y N Excessive sleepiness Emphysema Thyroid disease Y N Y N Fatigue Pneumonia Y N Y N Fever Shortness of breath Neurological Y N Y N Balance difficulty Depression Trouble breathing Y N Y N Choking Anxiety Tuberculosis Y N Y N Clumsiness Recent sore throat Wheezing Y N Concussion Sleep apnea Y N Confusion Musculoskeletal Weight loss or gain Connective tissue Y N Concentration difficulty disorder Dizziness Ears, Nose, & Throat Hearing loss Y N Y N Low back pain Drooling Y N Y N Mouth sores Neck pain Falls Y N Y N Ringing in ears Joint pain Hallucinations Y N Y N Sinus disease Joint replacement Headache Y N Y N Trouble swallowing Joint swelling Loss of consciousness Memory problems Eyes Genitourinary Muscle twitching Blurred vision Y N Blood in urine Y N Nausea Y N Y N Cataracts Change in habits Numbness Y N Y N Double vision Infections in urine Personality change Y N Y N Glaucoma Kidney disease Seizure Y N Y N Macular degeneration Kidney stones Shooting pains Y N Y N Peripheral vision issue Loss of control Smelling difficulty Y N Y N Visual impairment Painful urination Stroke Y N Urinary urgency Tasting difficulty Y N Gastrointestinal Vaginal bleeding Tingling sensation Black stool Y N Vertigo Y N Constipation Walking difficulty For Providers Only: Y N Diarrhea All others negative Y N Gall bladder problems Initial_________________ 05-480171000011 PLUE (1/2011)
Y Y Y Y Y Y Y Y Y Y Y Y Y
N N N N N N N N N N N N N
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
N N N N N N N N N N N N N N N N N N N N N N N N N
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Johns Hopkins Hospital
Johns Hopkins Community Physicians
Johns Hopkins Bayview
Other:
05-480171000011
Neurosurgery New Patient History Questionnaire
Patient Identification Information
SOCIAL HISTORY Gender:
Male
Female
Height: ______________
Weight: _________________ lbs.
What is your highest level of education? _______________________Are you disabled? Are you currently working?
Yes
No
Single
Married
Divorced
Separated
Living arrangement:
Alone
Roommate
Spouse
Children
Yes
No
No
If yes, What is your occupation? ___________________________
Marital Status:
Do you smoke?
Yes
Parents/sibling
If you smoked and quit, when did you quit? ________________________
If yes, how many packs/day? ______ How long have you been smoking? _______________________________ Do you drink alcohol?
Yes
No If, yes how many drinks/week? __________________________________
Do you drink caffeinated drinks (tea, coffee, soda, etc)
Yes
No
If Yes, how many drinks/week?____
FAMILY HISTORY If you have any relatives, including children, with serious medical conditions (such as asthma, high blood
pressure, heart attacks, kidney problems, diabetes, seizures, strokes, cancers, etc.) please list below. Relation____________________________________Age___________Condition_________________________ Relation____________________________________Age___________Condition_________________________ Relation____________________________________Age___________Condition_________________________ Relation____________________________________Age___________Condition_________________________ Relation____________________________________Age___________Condition_________________________ Relation____________________________________Age___________Condition_________________________ Do you have children?
Yes
No If yes, age(s) and condition____________________________________
__________________________________________________________________________________________ THIS FORM IS CONFIDENTIAL AND PART OF YOUR MEDICAL RECORD.
THANK YOU!
COMPLETED BY: PRINTED REVIEWED BY: 05-480171000011 PLUE (1/2011)
SIGNATURE M.D.
DATE
TIME
M.D. 4 of 4
2-Hole 1/4 2 3/4 - 3-Hole 1/4 4 1/4
“HOME*” MEDICATION LIST Name of recorder
Initials
Page ____ of ____
Addressograph Plate
Directions: List medications used by the patient prior to admission. “Home*” means the location of the patient just prior to admission. Patients may complete the gray area or provide a list, which will be reviewed on admission. IF MEDICATIONS ARE ADDED AFTER THE INITIAL COMPLETION OF THIS FORM, INITIAL/DATE ENTRY AND COMMUNICATE INFORMATION TO THE AUTHORIZED PRESCRIBER.
Allergies: “HOME*” MEDICATION LIST (CURRENT MEDS USED PRIOR TO ADMISSION)
(prescriptions, over-the-counter medications, herbals, vitamins, inhalers, eye drops, creams, ointments, parenteral nutrition etc.)
MEDICATION NAME
DOSE
ROUTE (e.g., by mouth or injection)
FREQUENCY (how often is it taken)
LAST DOSE (date/time)
USE ADDITIONAL FORM(S) AS NEEDED TO LIST ALL “HOME*” MEDICATIONS. ፬
Direct observation of patient’s medications ፬ Clinic note: date: _______ ፬ Obtaining history was not feasible (e.g., patient not conscious)
፬ ፬ ፬ ፬
Source of Medication History (check all that apply) ፬ Pharmacy (name/phone number) __________ Patient provided list Family provided list ፬ Primary physician (name/phone number) __________ Patient verbal recall ፬ Previous discharge paperwork (date: __________________________________) Family verbal recall ፬ Other ________________________
Signature of nurse verifying completion of the “Home*” Medication List
Date:
Time:
PLACE AS THE FIRST SHEET BEHIND THE “MEDICATION” MEDICAL RECORD TAB DO NOT THIN FROM CHART
15-144-100 (10/06)
MODIFICATIONS TO INITIAL “HOME” MEDICATION LIST DIRECTIONS: Record additional “home” medication information obtained after initial reconciliation has occurred and notify prescriber. Include over-the-counter (OTC) and herbal medications. Directly observed patient medications
Clinic note
(date:_______________)
Source of Additional Medication History (check all that apply) Patient provided list Pharmacy (name/phone number) ____________________________ Family provided list Primary physician (name/phone number)_______________________ Patient verbal recall Previous discharge paperwork (date: _____________________) Family verbal recall Other ___________________________________________________
DOSE (do not use volume, e.g., mL)
MEDICATION NAME
ROUTE
FREQUENCY
Prescriber notified (check)
Recorder (date/time, initials)
Name of recorder
15-144-100 (10/06)
Initials
Name of recorder
Initials
Name of recorder
Initials