Gary K. Alexander, MD, FACS New Patient History AGE:
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Gary K. Alexander, MD, FACS Texas Health Care, PLLC 1770 East Broad Street, Suite 102 Mansfield, TX 76063 New Patient History AGE: Name: _________________________________________ Date of birth: ________________________________ Best contact number: ____________________________ Primary physician: ____________________________ Who referred you: _______________________________ Last known height: _______ Last known weight: _______ Why are we seeing you today? Please list all of the medications that you take: include all over the counter, prescription and herbal medications, the dosage and how often that you take them. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Please list any ALLERGIES to Medication or Foods that you have. What reactions do you have (ie. Nausea, hives, shortness of breath)? i.e. PENICLLIN, SULFA, IODINE, EGGS, SHELLFISH, IV DYE ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Please indicate if you have any of the following medical conditions. Please list any condition that you have that is not included in the list below. Y N □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ Y N anemia anesthetic reaction angina/chest pain arthritis asthma bleeding problem bronchitis blood clots in legs blood clots in lungs chemotherapy circulation problems cirrhosis congestive heart failure □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ Y N COPD diabetes emphysema glaucoma gout heart attack heart murmur hepatitis high blood pressure high cholesterol high triglycerides HIV/AIDS irregular heart beat □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ kidney problems liver disease neurologic problems phlebitis (blood clots) pneumonia polycystic ovarian disease radiation rheumatic fever seizures sleep apnea stroke/TIAs tuberculosis ulcers Other:____________________________________________________________________________________ _________________________________________________________________________________________ Gary K. Alexander, MD, FACS Texas Health Care, PLLC 1770 East Broad Street, Suite 102 Mansfield, TX 76063 New Patient History Have you ever been diagnosed with a heart condition? □ Y □ N ____________________________________ Have you ever had or are scheduled to have a stress test or echocardiogram for your heart? If so when? Do you know the results? ___________________________________________________________ Have you ever been diagnosed with cancer or following conditions? Has anyone in your family ever been diagnosed with cancer or following conditions? Y N Y N Y N □ □ Prostate Cancer □ □ Thyroid Cancer □ □ Other Cancers: □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ □□ Barrett’s Esophagitis Breast Caner Colon Cancer Colon Polyps Esophageal Cancer Gastric Cancer Gastric Polyps Lymphoma _____________ _____________ Y N Barrett’s Esophagitis Breast Caner Colon Cancer Colon Polyps Esophageal Cancer Gastric Cancer Gastric Polyps Lymphoma □ □ Prostate Cancer □ □ Thyroid Cancer □ □ Other Cancers: _____________ _____________ Please list any blood relatives (parents, grandparents, siblings, aunts, uncles, cousins) who may have the following medical problems. Diabetes: High Blood Pressure: Heart Disease: Heart Attack: Stroke: Colon Polyps: Bleeding Disorders: Other: Have you ever used tobacco? Yes No What type? cigars cigarettes chewing tobacco How many per day? ___________ How many years? _______________ Have you tried to quit? Yes No Are you in close contact with other smokers? Yes No Do you drink alcohol? Never Socially Rarely Daily What do you drink? Beer Wine Liquor Do you consume caffeine? Never Coffee Tea Soda Cola Energy Drinks Do you have or ever had a chemical dependency? Never Current Former Recreational If you work outside of the home (or are retired), what type of work do you (did you) do? _______________________ Marital status: Single Married Widowed Divorced Blood Thinners: Aspirin, Motrin, Nuprin, Aleve, Plavix, Coumadin Have you traveled recently. If so, where? ___________________________________________________________ Gary K. Alexander, MD, FACS Texas Health Care, PLLC 1770 East Broad Street, Suite 102 Mansfield, TX 76063 New Patient History Have you ever had or been scheduled to have any Endoscopy or Colonoscopy? Yes No Results: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Please list any operations or hospitalizations you have had, and indicate the year. operation Appendix surgery Gallbladder surgery Hernia: side? Hemorrhoid surgery Breast Surgery: side? Bladder surgery C-section Tubal Ligation Hysterectomy Stomach surgery Colon surgery Weight Loss surgery year operation Thyroid surgery Heart surgery Angioplasty/Heart Catheterization Pacemaker Joint Surgery Back Surgery Kidney Surgery Laparoscopic Surgery Emergency Surgery Exploratory Surgery Tonsillectomy Other: year Has any part of your intestines ever been removed? Yes No __________________________________________________________________________________________ __________________________________________________________________________________________ Constitutional Head/Eyes/Ears/Nose/Throat _____ Fatigue _____ Fevers _____ Night sweats _____ Decrease in appetite _____ Increase in appetite _____ Weight gain _____ Weight loss _____ Night Sweats _____ Insomnia _____ Weakness _____ Malaise _____ Irritability _____ Lethargy _____ Chills/Rigors _____ Headaches _____ Recent visual changes _____ Double vision _____ Blurry vision _____ Eye pain _____ Runny nose _____ Nosebleeds _____ Sinus pain _____ Change in taste _____ Change in voice _____ Difficulty swallowing _____ Pain on swallowing _____ Sore throat _____ Swollen glands _____ Mouth sores _____ Tooth pain _____ Hearing loss _____ Ringing in the ears Musculoskeletal _____ Back Pain _____ Bone/Joint Pain _____ Muscle Pain _____ Muscle Weakness _____ Neck Stiffness _____ Arthritis _____ Gout Dermatologic _____ Acne _____ Hair Loss _____ Rash _____ Itching _____ New moles Gary K. Alexander, MD, FACS Texas Health Care, PLLC 1770 East Broad Street, Suite 102 Mansfield, TX 76063 New Patient History Respiratory Cardiovascular _____ Shortness of breath _____ Cough _____ Turning Blue _____ Coughing up blood _____ Pain with breathing _____ Wheezing _____ Daytime drowsiness _____ Snoring _____ Choking at night _____ Snoring/Sleep Apnea _____ Asthma _____ Pulmonary embolism _____ Exposure to asbestos _____ Tuberculosis exposure _____ Chest pain/angina _____ Heart attack _____ Swelling of ankles _____ Irregular heartbeat _____ Palpitations _____ Congestive heart failure _____ Coronary heart disease _____ Heart murmur _____ Blood clots/DVT _____ Numbness in your arm _____ Loss of pulse _____ Passing out Genitourinary Reproductive _____ Circumcised _____ Deceased Libido _____ Genital Sores _____ Infertility _____ Discharge _____ Testicular pain _____ Testicular mass _____ Previous groin hernia _____ Back pain _____ Cloudy/Dark urine _____ Frequent urination _____ Urinary urgency _____ Urinary incontinence _____ Blood in urine _____ Air in the urine _____ Bladder infections _____ Prostate problems _____ Kidney stones _____ Discharge Gynecologic _____ Vaginal infections _____ Irregular periods _____ Breast lumps _____ Nipple discharge Metabolic/Endocrine _____ Overweight _____ Underweight _____ Cold intolerance _____ Goiter _____ Hair loss _____ Heat intolerance _____ Changes in skin color _____ Excessive thirst _____ Numbness _____ Tremors Neuro/Psychiatric _____ Dizziness _____ Migraines _____ Headaches _____ Passed out _____ Seizures _____ Strokes _____ Memory loss _____ Shaking _____ Numbness _____ Tingling _____ Hearing Loss _____ Loss of sensation _____ Depression _____ Anxiety _____ Attention Deficit Vascular _____ Leg pain _____ Cold limb _____ Turning Blue _____ Redness in a limb _____ Leg or foot ulcers _____ Varicose veins _____ Numb limbs Gastrointestinal _____ Abdominal pain _____ Bloating _____ Blood in the stool _____ Change in appetite _____ H. Pylori infection _____ Hiatal hernia _____ Constipation _____ Diarrhea _____ Difficulty swallowing food _____ Difficulty swallowing water _____ Vomiting blood _____ Heartburn _____ Jaundice/yellowing _____ Weight loss _____ Rectal Bleeding _____ Hepatitis or cirrhosis _____ Diverticulitis _____ Irritable bowel _____ Change in bowel habits _____ Acid reflux _____ Pain on swallowing _____ Hemorrhoids _____ Incontinence _____ Abdominal Mass _____ Gallstones Hematologic/Immunologic _____ Easy Bleeding _____ Clotting problems _____ Bruising _____ Hives _____ Enlarged lymph nodes _____ Food allergies _____ Immune system problems 05/21/2015 Gary K. Alexander, MD, FACS General Surgery 1770 East Broad Street, Suite 102 Mansfield, TX 76063 09/05/1997 AGE: CONSULTATION VISIT Referring Physician: CC/Reason for Visit: HPI: Pain controlled narcotics OTC none nausea vomiting tolerating diet incision fever chills Vitals: Medications: Height: Weight: Temp: BP: HR: Resp: Pain: Allergies: Medical/Surgical History: Social History: Family History: Physical Exam: Assessment and Plan: Routine postop care CT Followup: PRN 2 weeks 4 weeks 6 weeks Driver License and Insurance information do NOT have to be filled out if cards were already given to reception Driver License and Insurance information do NOT have to be filled out if cards were already given to reception Driver License and Insurance information do NOT have to be filled out if cards were already given to reception Driver License and Insurance information do NOT have to be filled out if cards were already given to reception Gary K. Alexander, MD 1770 East Broad Street, Suite 102 Mansfield, TX 76063 Phone: (682) 518-8619 Fax: (682) 518-8195 Medical Release/ HIPAA Patient Name: ______________________________ DOB: ___________________ I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose my full and complete protected medical information/medical records to the following : Myself only: _____________ Voicemail / Telephone: _____________ Spouse/Partner: _____________ Other: _____________ Please provide name, date of birth, and relationship of the specified person: Patient Signature: _____________________________________________ Date: ___________________________
