File - Rocky Mountain Pulmonary and Critical Care
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Rocky Mountain Center for Clinical Research Name________________________________ Age________ Date of Birth_______________ Today’s Date____________ Address___________________________________________________________________________________________________ Phone: Home___________________________ Work____________________________ Cell____________________________ Primary Care Physician____________________________ Address and Phone_________________________________________ Any other specialists you see___________________________________________________________________________________ Emergency Contact Name and Phone Number ______________________________________________________________________ MEDICAL HISTORY (any medical conditions you have)_________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ SURGERIES AND HOSPITALIZATIONS (list all operations you have had or reason for hospitalization) Surgery / Hospitalization Date Surgery / Hospitalization ALLERGIES: Are you allergic to any medicines (including iodine, latex or anesthesia)? If yes, please complete: Allergy Type of Reaction Date Allergy Type of Reaction Date Date MEDICATIONS: List all medications, including inhalers, over the counter drugs, and supplements you have taken in the last 3 months: How often Medication/Indication Are you on oxygen? Dose per day Yes No How often Medication/Indication Dose per day How often Medication/Indication Dose per day If yes, how many liters/minute? ____________ How many hours/day? ____________ VACCINATIONS: Please circle and date all that apply: Pneumovax______________________ Flu______________________ TESTS/TREATMENTS/PROCEDURES: Have you ever had a chest x-ray? No Yes Date ________________________ SOCIAL HISTORY Occupation______________________________________ Any Toxic/Occupational Exposure?___________________ Marital Status M S D W # of children_______ Have you ever smoked? No Yes If you still smoke, how many years have you smoked_______How many packs per day________ If you’ve quit, how many years did you smoke____, _______ packs/day How many years ago did you quit______ Do you drink alcohol? No Yes If yes, #______per day Recreational Drug use? No Yes ___________________ Pets?____________________________________________ Foreign travel in the past year?________________________ Subject Signature __________________________________ Staff Signature _____________________________________ PLEASE COMPLETE ADDITIONAL QUESTIONS ON THE REVERSE SIDE Review of Systems / Medical History Have you been diagnosed with any of the following problems and/or are you currently having any of the following symptoms? Subject Name _______________________________________ Constitutional Unintended weight loss Unintended weight gain Fever Chills Night sweats Weakness Subject Name __________________________________ Review of Systems / Medical History Have you been diagnosed with any of the following problems, and/or are you currently having any of the following symptoms?
