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Johns Hopkins Hospital Johns Hopkins Bayview

Johns Hopkins Community Physicians

Other: 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)? 5. Does anything make the problem better? Yes No Explain:

6. Does anything make the problem worse? 7. Have you had treatment for the problem?

Yes No Yes No

Explain:

(2)

Johns Hopkins Hospital Johns Hopkins Bayview

Johns Hopkins Community Physicians

Other: Patient Identification Information

REVIEW OF SYSTEMS

Please circle the medical condition(s) below which apply to you either now or in the past.

Constitution Eyes Endocrine Allergies and Immunology

Activity change Eye discharge Cold intolerance Environmental allergies

Appetite change Eye itching Heat intolerance Food allergies

Chills Eye pain Polydipsia Immunocompromised

Diaphoresis Eye redness Polyphagia Neurological

Fatigue Photophobia Polyuria Dizziness

Fever Visual Disturbance Genitourinary Facial asymmetry

Unexpected wt change Respiratory Difficulty urinating Headaches

Head-Ears-Nose-Throat Apnea Dysuria Light-headedness

Facial swelling Chest tightness Enuresis Numbness

Neck Pain Choking Flank pain Seizures

Neck Stiffness Cough Frequency Speech difficulty

Ear Discharge Shortness of Breath Genital sore Syncope

Hearing Loss Stridor Hematuria Tremors

Ear pain Wheezing Penile discharge Weakness

Tinnitus Cardiovascular Penile pain Hematologic

Nosebleeds Chest Pain Penile swelling Adenopathy

Congestion Leg swelling Scrotal swelling Bruises/bleeds easily

Rhinorrhea Palpitations Testicular pain Psychiatric

Postnasal drip Gastrointestinal Urgency Agitation

Sneezing Abdominal distention Urine decreased Behavior Problem

Dental problem Abdominal pain Muscular Confusion

Drooling Anal bleeding Arthralgias Decreased concentration

Mouth sores Blood in stool Back pain Dysphoric mood

Sore throat Constipation Gait problem Hallucinations

Trouble swallowing Diarrhea Joint swelling Hyperactive

Voice change Nausea Myalgias Nervous/anxious

Rectal pain Skin Self-injury

Vomiting Color change Sleep disturbance

Pallor Suicidal ideas

Rash Wound

(3)

Johns Hopkins Hospital Johns Hopkins Bayview

Johns Hopkins Community Physicians

Other: Patient Identification Information

PAST MEDICAL HISTORY

Please mark all current medical problems and major illness you have had with approximate dates:

Other:

Date Date Date

ADD/ADHD Yes No Facial pain Yes No Myocardial infarction Yes No

Allergic rhinitis Yes No Gastritis Yes No Myopathy Yes No

Alzheimer

disease Yes No

Gastroesophageal

reflux disease Yes No NEC Yes No

Anemia Yes No Glaucoma Yes No Neck pain Yes No

Arrhythmia Yes No Gout Yes No Neuropathy Yes No

Arthritis Yes No Hearing loss Yes No Normal pressure

hydrocephalus Yes No

Asthma Yes No Hepatitis Yes No Obstructive

hydrocephalus Yes No

Back pain Yes No Herniated invertebral disk Yes No Osteoporosis Yes No

Cancer Yes No Hydrocephalus Yes No Parkinson's Yes No

Carotid

stenosis Yes No Hypercholesterolemia Yes No Peptic ulcer disease Yes No

Carpal tunnel Yes No Hyperglycemia Yes No Pneumonia Yes No

Celiac disease Yes No Hypertension Yes No Pseudomeningocele Yes No

Congestive

heart failure Yes No Hyperthyroidism Yes No Pseudotumor cerebri Yes No

Chiari

malformation Yes No Hypogonadism Yes No Scoliosis Yes No

Chronic kidney

disease Yes No Hypothyroidism Yes No Seizures Yes No

Chronic pain Yes No Intracranial aneurysm Yes No Self-catheterization (urinary) Yes No

Chronic obstructive pulmonary disease

Yes No Irritable bowel

syndrome Yes No Shingles Yes No

Coronary artery

disease Yes No Kidney stones Yes No Shunt infection Yes No

Dementia Yes No Lower extremity

edema Yes No Sinus thrombosis Yes No

Dermatological

disorder Yes No Lyme disease Yes No Sleep apnea Yes No

Diabetes Yes No Migraine Yes No Spinal stenosis Yes No

Diverticulosis Yes No Mitral/aortic valve

disease Yes No Stroke Yes No

Deep vein thrombosis / Pulmonary embolism

Yes No Morbid obesity Yes No Von Hippel-Lindau

disease Yes No

(4)

Johns Hopkins Hospital Johns Hopkins Bayview

Johns Hopkins Community Physicians

Other: Patient Identification Information

PAST SURGICAL HISTORY

Please mark all operations you have had in the past with approximate dates:

Other:

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:

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:

Date Date Date

Appendectomy Yes No Discectomy Yes No Shunt revision Yes No

Bariatric surgery Yes No Ear tubes Yes No Skin surgery Yes No

Brain tumor

resection Yes No

G-Tube/ PEG

placement Yes No

Spinal column tumor

resection Yes No

Breast biopsy Yes No Hernia repair Yes No Spinal fusion Yes No

Breast implant Yes No Hysterectomy Yes No Spine surgery Yes No

Coronary artery

bypass graft Yes No Joint surgery Yes No Splenectomy Yes No

Cardiac valve

surgery Yes No Laminectomy Yes No Stent Yes No

Carotid

endarterectomy Yes No Mastectomy Yes No Strabismus surgery Yes No

Carpal tunnel

release Yes No Myringotomy tubes Yes No

Subdural hematoma

drainage Yes No

Cholecystectomy Yes No Pituitary resection Yes No Tendon

lengthening/transfer Yes No

Clipping of intracranial aneurysm

Yes No Prostatectomy Yes No Thyroid surgery Yes No

Colon surgery Yes No Pseudomeningocele

repair Yes No Tonsillectomy Yes No

Coronary stent Yes No Radiosurgery Yes No Vascular surgery Yes No

(5)

Johns Hopkins Hospital Johns Hopkins Bayview

Johns Hopkins Community Physicians

Other: Patient Identification Information

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

SOCIAL HISTORY

Alcohol Use □Yes □No

Drinks/Week Glasses of wine Packs/day Cans of beer Shots of liquor

Drinks containing 0.5 oz of alcohol Sexually Active □Yes □No □Not Currently

Partners □Male □Female Birth Control /

Protection

Drug Use □Yes □No

Use/week Types

Gender: □ Male □Female Height:__________ Weight:_________lbs.

What is your highest level of education? ______________________________________ Are you disabled? □Yes □No Are you currently working? □Yes □No If yes, what is your occupation? ______________________________________ Marital Status: □Single □Married □Divorced □Separated

Living arrangement: □Alone □Roommate □Spouse □Children □Parents/sibling

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:_____________________________________________________________________________________ Tobacco Use

Years

Packs per day Quit Date

Smokeless Tobacco □Yes □No Quit Date

Ready to Quit □Yes □No

Counseling Given □Yes □No

(6)

Outpatient Medication List

Directions: Update and give a copy of this list to the patient with each outpatient visit. Do not use abbreviations.

q

Patient taking no medication regularly and none in the past 72 hours.

MEDICATIONS DOSE ROUTE

(include over-the-counter (e.g., strength, # of (e.g., by mouth, inhaled, FREQUENCY

and herbal medications) pills or drops) on skin) (how often)

Example: Vitamin C 250 mg By mouth Once a day

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

MEDICATION DOSE ROUTE FREQUENCY COMMENT

1.

2.

3.

4.

If you have questions about any of your medications, please contact the person who prescribed them.

600 North Wolfe Street Baltimore, mD 21287

New Medications – Please enter all new medications below.

Please use additional sheet for more medications.

OUTPTMEDLIST (Rev 8/10) / /

_________________________________________________________ __________________________ _______________

Reviewed by (Name and credentials of health care provider) Date Time

Patient Name

JH Medical Record #:

References

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