NEPHROLOGY ASSOCIATES OF NORTHEAST FLORIDA PATIENT HISTORY FORM
JACKSONVILLE OFFICE
James D. Baker III M.D., Michael B. Brumback M.D., James B. Smart Jr. M.D Aalok Kuthiala M.D.,
Deborah A. Price M.D, Craig J. Shapiro M.D., Muhammad Salahuddin M.D.,
Laurie L. Buschini MSN ARNP, Joseph L. Ernst PA-C, Sara Preston, A.R.N.P.
ORANGE PARK OFFICE
David H. Michal, M.D., Ramesh M. Kotihal, M.D., Waqas Ahmed, M.D., Cindy Anderson, PA-C
PLEASE FILL OUT THE FORM AS ACCURATELY AS POSSIBLE. THE INFORMATION WILL BE ENTERED INTO YOUR PERMANENT RECORD
NAME: ___________________________________________ DOB: ____________________ DATE: ______________________________
MD NOTES and CC: ________________________________________________________________________________________________
_________________________________________________________________________________________________________________
I. DO YOU HAVE:
YES NO
KNOWN KIDNEY DISEASE
URINATION AT NIGHT
FREQUENT URINATION
BURNING ON URINATION
DIFFICULTY URINATING
KIDNEY/BLADDER INFECTION
PROTEIN / FOAMY URINE
BLOOD IN URINE
KIDNEY STONES
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
M.D. NOTES
______________
______________
______________
______________
______________
______________
______________
______________
______________
YES NO
M.D. NOTES
DIABETES IN EYES (Laser Treatment) Y N Date: ___________
DIABETES IN NERVES (Neuropathy)
Y N ________________
PROSTATE INFECTION
Y N ________________
PAIN WITH WALKING (PAD/PVD)
Y N ________________
HEARING LOSS
Y N ________________
SINUSITIS
Y N ________________
HERBAL MEDICINES
Y N ________________
CHILDHOOD NEPHRITIS
Y N ________________
CONSISTENT USE OF Non-Steroidal
Y N ________________
(Motrin, Ibuprofen, Aleve, Goody, Naproxen, Indocin, Mobic, Excedrin)
II. LIST MEDICAL PROBLEMS WITH APPROXIMATE YEAR DIAGNOSED:
Medical Problem
Year
Medical Problem
1.
7.
2.
8.
3.
9.
4.
10.
5.
11.
6.
12.
Year
III. DRUG ALLERGIES AND TYPE OF REACTION: ____________________________________________________________________
IV. PLEASE LIST MEDICINES INCLUDING OVER THE COUNTER AND HERBALS AND/OR BRING TO CLINIC VISIT:
Medication with dose and frequency per day
Medication with dose and frequency per day
1.
8.
2.
9.
3.
10.
4.
11.
5.
12.
6.
13.
7.
14.
2
SURGEON:
V. LIST ALL SURGERIES:
APPROXIMATE DATE:
________________________________________________________
___________________________
_____________________
________________________________________________________
___________________________
_____________________
________________________________________________________
___________________________
_____________________
________________________________________________________
___________________________
_____________________
VI. FAMILY HISTORY:
YES NO
KIDNEY DISEASE
HEART DISEASE
HIGH BLOOD PRESSURE
Relationship
______________________
______________________
______________________
YES NO
DIABETES
CANCER
STROKE
Relationship
__________________________
___________________________
___________________________
VII. SOCIAL HISTORY:
HAVE YOU EVER SMOKED? YES
NO
PACKS PER DAY: _________ FOR _________ YEARS QUIT IN _____________
DO YOU DRINK ALCOHOL? YES
NO
DRINKS PER DAY: ________ FOR _________ YEARS QUIT IN _____________
ARE YOU: SINGLE / MARRIED / DIVORCED / WIDOWED
RETIRED OCCUPATION:__________________________________
VIII. REVIEW OF SYMPTOMS (CHECK ANY THAT REGULARLY OCCUR):
CONSTITUTIONAL:
FATIGUE
FEVER
CHILLS
NIGHT SWEATS
CHANGE IN APPETITE OR WEIGHT
______________________________________________________________________________________________________________
HEENT:
MIGRAINES
SEVERE HEADACHE
DOUBLE VISION
LOSS OF CONSCIOUSNESS
HAYFEVER/SINUSITIS
NOSE BLEEDS
RINGING IN THE EARS
FREQUENT SORE THROAT
BLURRY VISION
HOARSENESS
______________________________________________________________________________________________________________
PULMONARY:
ASTHMA
TUBERCULOSIS
UNRESOLVING PNEUMONIA
WHEEZING
PERSISTENT COUGH
COUGHING UP BLOOD
SHORTNESS OF BREATH WITH EXERCISE
ASBESTOS / SILICA CONTACT
______________________________________________________________________________________________________________
HEART:
HEART ATTACK
IRREGULAR OR RAPID HEART BEAT
CHEST PAIN/TIGHTNESS
TROUBLE LYING FLAT
______________________________________________________________________________________________________________
GASTROINTESTINAL:
DIVERTICULI/HEMMORHOIDS
LIVER DISEASE/HEPATITIS
ULCERS
DIARRHEA
CONSTIPATION
BLACK TARRY STOOL OR BLOOD IN STOOL
VOMITING BLOOD
TROUBLE SWALLOWING
______________________________________________________________________________________________________________
MUSC:
SWOLLEN JOINTS
WEAKNESS
ARTHRITIS
OSTEOPOROSIS
BACK PAIN
MUSCLE PAIN
RASHES
______________________________________________________________________________________________________________
NEUROLOGIC:
SEIZURES
NUMBNESS
STROKE
VERTIGO
LOSS OF BALANCE
PSYCHOLOGIC TREATMENT
______________________________________________________________________________________________________________
ENDOCRINOLOGIC:
THYROID DISEASE
HOT/COLD SENSITIVITY
EXCESSIVE WATER DRINKING
______________________________________________________________________________________________________________
HEMATOLOGIC:
INTEGUMENTARY:
ANEMIA
EASY BRUISING
SKIN CHANGES :
BLOOD TRANSFUSION
ULCERS (i.e. Diabetic)
SWOLLEN LYMPH GLANDS
BLOOD CLOT
LESIONS _________________________________________
OTHER: _______________________________________________________________________________________________________
3
PROCEDURES: PLEASE BRING COPIES OF ANY AVAILABLE STUDIES BELOW:
Sigmoid/Colonoscopy
DATE: __________
DOCTOR: ___________________________
Cystoscopy (Bladder):
DATE: __________
DOCTOR: ___________________________
Eye Exam:
DATE: __________
DOCTOR: ___________________________
Heart Cath:
DATE: __________
DOCTOR: ___________________________
EKG:
DATE: __________
DOCTOR: ___________________________
THE FOLLOWING SECTIONS ARE FOR OFFICE USE ONLY
VITAL SIGNS:
EYES:
See Vital Log GENERAL:
Conjunctiva clear
ENT:
Oropharynx clear
Neck:
soft, supple
PVD:
No Carotid Bruit
CVS:
S1, S2
Pulmonary:
Abdomen:
Back:
Musc:
Skin:
trachea is midline
No abdominal bruit
regular rate and rhythm
soft NT
EOMI _____________________________________________
no thyroid tenderness____________________________________
no rubs or gallops
no gross masses, HSM or distention
obese _______________________________
No Spinal Tenderness _________________________________________________________
No cyanosis, clubbing
No warm or swollen joints
peripheral pulses intact,
edema ______________________________________
Stable ROM in all extremities _____________________________________________
No new rashes/lesions
No ulcerations __________________________________________________
Alert, awake and oriented to person place and time
Neuro:
Moves all 4 extremities equally
None in Head
Murmurs______________________________________
CTA B/L _______________________________________________
Psych :
LAD:
No gingival hyperplasia or bleeding ______________
Peripheral pulses intact________________________________________
Symmetric Expansion
normal BS
No CVA tenderness
warm, dry
PERRL
NAD __________________________________________
Mucosa moist w/o erythema or exudate
symmetric
Good effort
Extremities:
Sclera anicteric
WDWN
DICTATED
DTRs symmetric
None in Neck
judgment and insight appropriate ______________________
Strength __/5 _____________________________________
None in Groin
None in Axilla ____________________________
Labs and Imaging Reviewed
Hospital Data Reviewed
ASSESSMENT AND PLAN:
1. _____________________________________________________________________________________________________
2. _____________________________________________________________________________________________________
3. _____________________________________________________________________________________________________
4. _____________________________________________________________________________________________________
5. _____________________________________________________________________________________________________
6. _____________________________________________________________________________________________________
Physician Signature ____________________________ Date: _____________
REVISED 2/20/2015