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:
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:
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
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
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
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
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 #: