01.B
DIVISION OF VASCULAR SURGERY
PATIENT INTAKE FORM – ESTABLISHED PATIENTS
Date of appointment__________________
Your Name___________________________________________ DOB_________________ Age________
What is the main problem today?____________________________________________________________
Physician contact information: PLEASE INCLUDE FIRST NAMES IF YOU KNOW THEM (our computers are dumb!):
Who is your primary care MD? ___________________________________________________________
Who is your cardiologist?
N/A
________________________________________________________
Who is your nephrologist?
N/A
________________________________________________________
At what center do you receive dialysis?
_________________________________________________
Any other doctors we should send info to? _________________________________________________
What are your main (active or inactive) medical problems? ________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Any symptoms you are NOW having, or other things to discuss?_____________________________________
_________________________________________________________________________________________
Any changes in your health (or recent surgery) since we last saw you?________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
NO OTHER CHANGES SINCE LAST VISIT – no need to fill out anything further unless needed.
Revised 05-10-14
PAGE 1
Any medication changes since we’ve seen you last?
DOSE
Times/day
________________________________________________
_______________
________________
________________________________________________
_______________
________________
________________________________________________
_______________
________________
What are your allergies?____________________________________________________________________
Risk factors:
Do you smoke?
YES
Do you drink?
YES NO
Do you have COPD?
NO
If yes, packs/day: __________
Year quit: _____________
If yes, drinks per day: __________ per week:____________
YES
Are you on oxygen?
YES
Please circle any recent or ongoing symptoms that bother you NOW:
Constitutional:
Fever
Chills
Fatigue
Weight loss
Eyes:
Double vision
Eye injury
Blurry vision
Eye surgery
Glaucoma
Color blindness
Head and neck:
Sinusitis
Mouth sores
Hearing loss
Voice change
Ringing in ears
Neck swelling
Cardiovascular:
Chest pain
High BP
Palpitations
Leg swelling
Respiratory:
Short of breath
Spitting blood
Asthma
Cold/flu
Cough
Bronchitis
Wheezing
Pneumonia
Gastrointestinal:
Poor appetite
Constipation
Nausea
Blood in stool
Vomiting
Diarrhea
Genitourinary:
Frequent
UTI
Painful urination
Incontinence
Erectile dysfunction
Irregular periods
Musculoskeletal:
Arthritis
Leg swelling
Night cramps
Spinal stenosis
Skin:
Rashes
Ulcers
Nail changes
Neurologic:
Stroke, TIA
Headaches
Dizziness
Seizures
Psychological:
Depression
Memory loss
Dementia
Anxiety
Endocrine:
Diabetes
Hyperthyroid
Hypothyroid
Excessive thirst
Hematologic:
Easy bruising
Bleeding problem
DVT or phlebitis
Weight gain
Balance loss
Physician Review: ________________________________________ Date _______________________
Revised 05-10-14
PAGE 2