Microsoft word - patient history form (04-07-11).doc
PATIENT HISTORY FORM FOR ARTHUR F. SMITH, MD NAME: ________________________________________________
AGE: ______ SEX M___ F ___ DATE: _____________
If you are on DIALYSIS, please notify the front desk immediately. (SOME MEDICARE POLICIES ONLY COVER DIALYSIS AND NOT DERMATOLOGY VISITS) REASON FOR VISIT (MAIN PROBLEMS): CHECK GROWTHS FOR SKIN CANCER NEW GROWTH(S) OLD GROWTH(S) NEW RASH WORSENING RASH PLEASE FINISH THIS PAGE. PLEASE FILL OUT RASH QUESTIONAIRE (NEXT PAGE) ONLY IF YOU ARE HERE FOR A RASH. PLEASE EXPLAIN THE REASON FOR YOUR VISIT: ________________________________________________________________________________ ____________________________________________________________________________________________________________________________ MEDICATION LIST: PLEASE LIST ALL YOUR MEDICATIONS INCLUDING ASPIRIN, VITAMINS, OVER THE COUNTER DRUGS, TOPICAL MEDICATIONS AND EYEDROPS AND WHAT DISEASE THEY ARE TAKEN FOR. PCP _______________________________________
MEDICATION / PROBLEM BEING TREATED MEDICATION / PROBLEM BEING TREATED ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ DO YOU TAKE COUMADIN, PLAVIX, ASPIRIN, VITAMIN E, ST JOHNS WART(CIRCLE)
ALLERGIES and REACTIONS to drugs or topical agents: Penicil in, Keflex, Sulfa, Tetracycline (CIRCLE) or other medications—if so, state which ones:
__________________________________________________________________________________________________________________________ VERY IMPORTANT TO FILL OUT PROBLEMS AND DISEASES: PLEASE CIRCLE ANY OF THE FOLLOWING THAT PERTAINS TO YOU: Actinic keratoses / squamous cel / basal cell / melanoma / Psoriasis /Seborrheic dermatitis / Eczema / Acne / Contact dermatitis AIDS Allergies Angina Arthritis (Type:_________) Asthma Artificial heart valves Artificial joints (hips knees) Cancer(Type:_______________) Diabetes Heart Disease Heart mumur Heart Failure High Cholesterol/TG’s High Blood Pressure Inflammatory Bowel Disease Hay Fever Hepatitis Kidney Disease Liver Disease Lung Disease Parkinson’s Stroke
Tuberculosis Ulcers Please LIST ALL OTHER MEDICAL ILLNESSES NOT IDENTIFIED ABOVE:________________________________________________________________ ______________________________________________________________________________________________________________________________
REVIEW OF SYSTEMS: DO YOU HAVE NOW, OR HAVE YOU HAD DISEASES OR CONDITIONS LISTED BELOW? PLEASE CHECK. IF NOT CIRCLED ANSWER IS NO.
_______________________________________________________________________________________________________________________ PAST MEDICAL, FAMILY, AND SOCIAL HISTORY: Is there a Family History of any of the following? Melanoma Y/N Basal Cel Carcinoma Y/N Squamous cel carcinoma Y/N Eczema Y/N Psoriasis Y/N
Lupus Y/N Fungus Y/N SOCIAL HISTORY: Please circle any of the significant exposures Past or Present: Smoking Drinking Occupation Golf Tennis Sports Gardening/Yard work Beach Boating Swimming Fishing Walking Other Hobbies:_____________________________________________________________________________________ Please list previous occupations or other significant SUN exposures:_______________________________________________________________________
PATIENT SIGNATURE___________________________________________________PHYSICIAN SIGNATURE____________________________________ PATIENT HISTORY FORM (04-07-11).doc 6/25/12 6:00 PM ARTHUR F. SMITH, M.D
RASH QUESTIONAIRE FOR PATIENTS WITH A RASH ONLY FILL OUT THIS PAGE ONLY IF YOU HAVE A NEW RASH
Please give information regarding your present RASH OR RASHES:
1____________________________________________________________________________________________________________________________
2_____________________________________________________________________________________________________________________________
3_____________________________________________________________________________________________________________________________
PLEASE LIST ALLORAL AND TOPICAL MEDICATIONS AND LOTIONS YOU USED TO TREAT THIS RASH._________________________________
__________________________________________________________________________________________________________________________
1. Location: (Please circle) scalp face ears neck chest abdomen back genitals groin buttocks legs feet nails hair
2. Duration: (How long have you had this problem?) _____days _____weeks _____months _____years
3. Signs (Does your rash have any: (Please circle) scratch marks/ purple marks/ pus/ blisters/ cracks / thick areas
4. Symptoms/Quality: (Please circle) itch pain burn tender swel ing ulcer other ________________
5. Related signs and symptoms (Please circle): fever / flu like symptoms/ painful joints (arthralgias)/ sore throat/ none
6. Modifying factors: Medications or treatments that: helped __________________________ aggravated ___________________________________
7. Severity: (Please circle) mild / moderate/ severe
8. Context: Does problem relate to any activity or environmental factors (sun)? No ____Yes (please explain)_________________________________
9. Timing: Does problem relate to work ,hobbies, housework, cleaning etc.____________________________________________________________
10. Do you use any of the fol owing: Ponds/ Oil of Olay/ Eucerin/ Vaseline Intensive care/ vitamin E containing products/Neosporin/Bacitracin
Triple antibiotic ointment/Topical Benadryl/ Caladryl / Lanacaine / Irish Spring/ Coast/ Safeguard / Lever 2000
Other cosmetics, moisturizers, soaps, toothpastes and anything else being applied to the skin. Everything is important to report.
PATIENT HISTORY FORM (04-07-11).doc 6/25/12 6:00 PM ARTHUR F. SMITH, M.D
Dr. Kevin Byrne, DVM, MS Diplomate American College of Veterinary Dermatology Patient History Form List any drug allergies: ____________________ This information will help us help your pet. 1. What are your pet’s problems currently : (check all that apply)Scratching, chewing, licking, rubbing, skin ( )Red bumps, pimples, scabs ( )Ear infections ( )Nail infections or nail loss ( )O
APPENDIX 3e TABLE 1 - NON-BULKY COMPARISON GOODS CENTRE MARKET SHARES (COLUMN PERCENT) GDA Hinterland Longford CENTRE NAME Dublin City Dublin Fingal South Dublin Dublin Dun Laoghaire- Cavan and Offaly and Carlow and Wexford Rathdown Monaghan and West Kilkenny Zone 10 Zone 11 Zone 12 Zone 13 Zone 14 Zone 15 Zone 16 Zone 17 Zone 18 Zone 19 Zone 20 Zone