Return this form at least 5 days prior to your appointment.
If this form is not returned your appointment may be cancelled.
You may fax this form back to 317-872- 1186.
PATIENT INFORMATION SHEET
ARREGUI, DAVIS, SINGH & MATHAVAN MDs, INC
Appt Date
_____
_ _ ___.
_ _ ___. SinghDMathavan
DEMOGRAPHICS
Female
Ml _ _
Gender _
_ _ __
First Name
Last Name
_ _ _ _ _ _ _ _ Date of Birth _ _ _ _ _ _ _ Marital Status - - - - - - - - SSN
--------
Street
City/State/Zip - - - - - - - - - - - - - -
Home Phone
------------ Work Phone
- - - - - - - " 'Employer
Email: ____________
Cell#
______ _ ___ _ ____ _
INSURANCE
Primary
Secondary
Other
Carrier _ _ _ _ _ _ _ Carrier
Carrier
ID# _ _ _ _ _ _ _ _
ID#
Group#
Group #
ID#
Group #
EMERGENCY CONTACT
#1Last Name
First Name _ _ _ _ _ __
Relationship - - -
------ - - ---
Home Phone
Work Phone
Cell/Pager#
#2 Last Name
First Name - - - - - - - - - - Relationship
Home Phone - - - - - - - Work Phone ______ ___ Cell/Pager#
PHYSICIANS
REFERRING
Last Name
First Name
Office Phone#
FAMILY
Last Name
First Name
Office Phone#
CARDIOLOGIST
Last Name
First Name
Office Phone#
OTHER
OTHER
OTHER
Last Name
Last Name
Last Name
First Name
First Name
First Name
Office Phone#
Office Phone#
Office Phone#
PREVIOUS SURGERIES & PROCEDURES
TYPE OF SURGERY/YEAR OF SURGERY
TYPE OF SURGERY/YEAR OF SURGERY
5
2
3
4
8
4
8
6
7
Y
Tobacco Use (Circle all that apply)
N
When did you quit smoking:
Do You Smoke or Chew Tobacco: YES or NO
If yes or if you quit, how many pks per day:
How many years did you or have you smoked: _ _ _ _ __
Daily _______ Occ.
ALCOHOL USE (CHECK WHICH APPUES)
Heavy_ _ __
Socially_ _ __
Never
PAST MEDICAL HISTORY
CHECK ANY OF THE FOLLOWING CONDITIONS THAT APPLY & DESCRIBE THE CONDITION
Heart Disease
YES
NO
Pacemaker or Defibrillat or
YES
NO
Lung Problems or Asthma
High Blood Pressure
Diabetes
YES
YES
NO
NO
YES
No
Colon or Bowel
YES
NO
Cancer
YES
NO
Stroke or Mini Stroke
YES
NO
Bleeding Tendencies
YES
NO
Blood Clots or Cellulitis
YES
NO
Others (please list)
YES
NO
Make/Modei#/Serial#
PRESCRIPTION MEDICATIONS
Medication
2
3
Dose/Frequency
Medication
7
8
5
9
10
11
6
12
4
Dose/Frequency
NON-PRESCRIPTION MEDICATIONS
OVER-THE-cOUNTER {INCLUDING ASPIRIN)
HERBAL PREPARATIONS & DIETARY SUPPLEMENTS
2
3
4
5
6
2
3
4
5
6
ARE YOU ALLERGIC TO ANY MEDICATIONS, FOODS OR PRODUCTS?
3
2
4
WHAT TYPE OF REACTION?
FAMILY MEDICAL HISTORY (Do any family members, alive or deceased, have medical problems?)
,,____ ______ __________________
2. ________________________ _
5. ___________________________ _
3._____ __________________ _
6. ____________________ ------ - ?. _ ________________________ _
4.______ ______
8. ________________________ _
REVIEW OF SYSTEMS
(Circle any of the following you currently experience)
General
Weight loss
Neurological
I No
Allergic/Immunologic
Yes I No
Headache
Seasonal allergies
Yes I No
Weight gain
Yddes I No
Fever
Yes I No
Numbness
Yes I No
persistent infections
Yes I No
Fatigue
Yes I No
Slurred speech
Yes I No
Psychologic
Yes I No
Yes I No
Anxiety
Yes I No
Eyes
Yes I No
Confusion
Dizziness/Vertigo
hives
Yes I No
Pain
Yes I No
Extremity Weakness
Yes I No
Depression
Yes I No
Discharge
Yes I No
Extremity Paralysis
Yes I No
Severe stress
Yes I No
Light sensitivity
Blurred vision
ENT
Sore throat
Hoarseness
Ear ringing
Nose bleeds
Respiratory
Wheezing
Cough
Shortness of breath
Chest congestion
Cardiovascular
Chest Pain
Fainting
Swelling of feet
Palpitations
Swelling of hands
Genitourinary
Painful urination
Hesitancy
Urgency
Blood in urine
Flank pain
Yes I No
Yes I No
Musculoskeletal
Joint swelling
Joint pain
Back pain
Muscle cramps
Muscle weakness
Skin
Rash
Itching
Sores
Abscess
Discharge
Endocrine
Excessive sweating
Excessive thirst
Heat intolerance
Excessive urination
Excessive hunger
Hematologic/Lymph
Lymph node swelling
Easy bruising
Bleeding
Skin discoloration
Panic Attacks
Gastrointestinal
Abdomen pain
Unusual belching
Nausea
Vomiting
Diarrhea
Constipation
Blood in stool
Dark, tarry stool
Bloating
Change in bowel habits
Indigestion
Excessive gas
Difficul1 ty Swallowing
Yellow skin color
Yes I No
Yes
Yes
Yes
Yes
I
I
I
I
No
No
No
No
Yes
Yes
Yes
Yes
I
I
I
I
No
No
No
No
Yes
Yes
Yes
Yes
Yes
I
I
I
I
I
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
I
I
I
I
I
No
No
No
No
No
HEIGHT-------
Yes
Yes
Yes
Yes
Yes
I
I
I
I
I
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
I
I
I
I
I
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
I
I
I
I
I
No
No
No
No
No
Yes
Yes
Yes
Yes
I
I
I
I
No
No
No
No
History of the following:
MRSA
VRE
WEIGHT ____, _
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
I
I
I
I
I
I
I
I
I
I
I
I
I
I
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes I No
Yes I No