ࡱ> ] 4bjbj ;ee,3#####7778ol7;H{. , *|/hGGGGGGG$'JLG#2 22G##G4442##G42G44C|FE }I3JDG H0;H\DM74XM$FEFEM#ZEL1"24222111GG4^111;H2222M111111111 :  NEPHROLOGY ASSOCIATES OF NORTHEAST FLORIDA PATIENT HISTORY FORM JACKSONVILLE OFFICE Michael B. Brumback M.D., James B. Smart Jr. M.D ., Deborah A. Price M.D, Craig J. Shapiro M.D., Muhammad Salahuddin M.D., Andreea Poenariu, M.D., Juan L. Chique, M.D. Laurie L. Buschini MSN ARNP, Joseph L. Ernst PA-C, Sara Preston, A.R.N.P., Alexandra Michaelis, A.R.N.P. ORANGE PARK OFFICE Ramesh M. Kotihal, M.D., Reuben Maggard, 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 M.D. NOTES YES NO M.D. NOTES KNOWN KIDNEY DISEASE Y N ______________ DIABETES IN EYES (Laser Treatment) Y N Date: ___________ URINATION AT NIGHT Y N ______________ DIABETES IN NERVES (Neuropathy) Y N ________________ FREQUENT URINATION Y N ______________ PROSTATE INFECTION Y N ________________ BURNING ON URINATION Y N ______________ PAIN WITH WALKING (PAD/PVD) Y N ________________ DIFFICULTY URINATING Y N ______________ HEARING LOSS Y N ________________ KIDNEY/BLADDER INFECTION Y N ______________ SINUSITIS Y N ________________ PROTEIN / FOAMY URINE Y N ______________ HERBAL MEDICINES Y N ________________ BLOOD IN URINE Y N ______________ CHILDHOOD NEPHRITIS Y N ________________ KIDNEY STONES 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 ProblemYearMedical ProblemYear1. 7.2. 8.3. 9.4. 10.5. 11.6. 12. 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 dayMedication with dose and frequency per day1. 8.2. 9.3.10.4.11.5.12.6.13.7.14. V. LIST ALL SURGERIES: SURGEON: APPROXIMATE DATE: ________________________________________________________ ___________________________ _____________________ ________________________________________________________ ___________________________ _____________________ ________________________________________________________ ___________________________ _____________________ ________________________________________________________ ___________________________ _____________________ VI. FAMILY HISTORY: YES NO Relationship YES NO Relationship KIDNEY DISEASE  FORMCHECKBOX   FORMCHECKBOX  ______________________ DIABETES  FORMCHECKBOX   FORMCHECKBOX  __________________________ HEART DISEASE  FORMCHECKBOX   FORMCHECKBOX  ______________________ CANCER  FORMCHECKBOX   FORMCHECKBOX  ___________________________ HIGH BLOOD PRESSURE  FORMCHECKBOX   FORMCHECKBOX  ______________________ STROKE  FORMCHECKBOX   FORMCHECKBOX  ___________________________ VII. SOCIAL HISTORY: HAVE YOU EVER SMOKED? YES  FORMCHECKBOX  NO  FORMCHECKBOX  PACKS PER DAY: _________ FOR _________ YEARS QUIT IN _____________ DO YOU DRINK ALCOHOL? YES  FORMCHECKBOX  NO  FORMCHECKBOX  DRINKS PER DAY: ________ FOR _________ YEARS QUIT IN _____________ ARE YOU: SINGLE / MARRIED / DIVORCED / WIDOWED  FORMCHECKBOX  RETIRED OCCUPATION:__________________________________ VIII. REVIEW OF SYMPTOMS (CHECK ANY THAT REGULARLY OCCUR): CONSTITUTIONAL:  FORMCHECKBOX  FATIGUE  FORMCHECKBOX  FEVER  FORMCHECKBOX  CHILLS  FORMCHECKBOX  NIGHT SWEATS  FORMCHECKBOX  CHANGE IN APPETITE OR WEIGHT ______________________________________________________________________________________________________________ HEENT:  FORMCHECKBOX  MIGRAINES  FORMCHECKBOX  SEVERE HEADACHE  FORMCHECKBOX  LOSS OF CONSCIOUSNESS  FORMCHECKBOX  RINGING IN THE EARS  FORMCHECKBOX  BLURRY VISION  FORMCHECKBOX  DOUBLE VISION  FORMCHECKBOX  HAYFEVER/SINUSITIS  FORMCHECKBOX  NOSE BLEEDS  FORMCHECKBOX  FREQUENT SORE THROAT  FORMCHECKBOX  HOARSENESS ______________________________________________________________________________________________________________ PULMONARY:  FORMCHECKBOX  ASTHMA  FORMCHECKBOX  TUBERCULOSIS  FORMCHECKBOX  WHEEZING  FORMCHECKBOX  PERSISTENT COUGH  FORMCHECKBOX  COUGHING UP BLOOD  FORMCHECKBOX  UNRESOLVING PNEUMONIA  FORMCHECKBOX  SHORTNESS OF BREATH WITH EXERCISE  FORMCHECKBOX  ASBESTOS / SILICA CONTACT ______________________________________________________________________________________________________________ HEART:  FORMCHECKBOX  HEART ATTACK  FORMCHECKBOX  IRREGULAR OR RAPID HEART BEAT  FORMCHECKBOX  CHEST PAIN/TIGHTNESS  FORMCHECKBOX  TROUBLE LYING FLAT ______________________________________________________________________________________________________________ GASTROINTESTINAL:  FORMCHECKBOX  DIVERTICULI/HEMMORHOIDS  FORMCHECKBOX  ULCERS  FORMCHECKBOX  DIARRHEA  FORMCHECKBOX  CONSTIPATION  FORMCHECKBOX  VOMITING BLOOD  FORMCHECKBOX  LIVER DISEASE/HEPATITIS  FORMCHECKBOX  BLACK TARRY STOOL OR BLOOD IN STOOL  FORMCHECKBOX  TROUBLE SWALLOWING ______________________________________________________________________________________________________________ MUSC:  FORMCHECKBOX  SWOLLEN JOINTS  FORMCHECKBOX  WEAKNESS  FORMCHECKBOX  ARTHRITIS  FORMCHECKBOX  OSTEOPOROSIS  FORMCHECKBOX  BACK PAIN  FORMCHECKBOX MUSCLE PAIN  FORMCHECKBOX  RASHES ______________________________________________________________________________________________________________ NEUROLOGIC:  FORMCHECKBOX  SEIZURES  FORMCHECKBOX  NUMBNESS  FORMCHECKBOX  STROKE  FORMCHECKBOX  VERTIGO  FORMCHECKBOX  LOSS OF BALANCE  FORMCHECKBOX  PSYCHOLOGIC TREATMENT ______________________________________________________________________________________________________________ ENDOCRINOLOGIC:  FORMCHECKBOX  THYROID DISEASE  FORMCHECKBOX  HOT/COLD SENSITIVITY  FORMCHECKBOX  EXCESSIVE WATER DRINKING ______________________________________________________________________________________________________________ HEMATOLOGIC:  FORMCHECKBOX  ANEMIA  FORMCHECKBOX  EASY BRUISING  FORMCHECKBOX  BLOOD TRANSFUSION  FORMCHECKBOX  SWOLLEN LYMPH GLANDS  FORMCHECKBOX  BLOOD CLOT INTEGUMENTARY:  FORMCHECKBOX  SKIN CHANGES :  FORMCHECKBOX  ULCERS (i.e. Diabetic)  FORMCHECKBOX  LESIONS _________________________________________ OTHER: _______________________________________________________________________________________________________ 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  FORMCHECKBOX  DICTATED VITAL SIGNS:  FORMCHECKBOX  See Vital Log GENERAL:  FORMCHECKBOX WDWN  FORMCHECKBOX  NAD __________________________________________ EYES:  FORMCHECKBOX Conjunctiva clear  FORMCHECKBOX  Sclera anicteric  FORMCHECKBOX  PERRL  FORMCHECKBOX  EOMI _____________________________________________ ENT:  FORMCHECKBOX  Oropharynx clear  FORMCHECKBOX Mucosa moist w/o erythema or exudate  FORMCHECKBOX  No gingival hyperplasia or bleeding ______________ Neck:  FORMCHECKBOX  soft, supple  FORMCHECKBOX  symmetric  FORMCHECKBOX  trachea is midline  FORMCHECKBOX no thyroid tenderness____________________________________ PVD:  FORMCHECKBOX  No Carotid Bruit  FORMCHECKBOX  No abdominal bruit  FORMCHECKBOX  Peripheral pulses intact________________________________________ CVS:  FORMCHECKBOX  S1, S2  FORMCHECKBOX  regular rate and rhythm  FORMCHECKBOX  no rubs or gallops  FORMCHECKBOX  Murmurs______________________________________ Pulmonary:  FORMCHECKBOX Good effort  FORMCHECKBOX  Symmetric Expansion  FORMCHECKBOX  CTA B/L _______________________________________________ Abdomen:  FORMCHECKBOX soft NT  FORMCHECKBOX  normal BS  FORMCHECKBOX  no gross masses, HSM or distention  FORMCHECKBOX  obese _______________________________ Back:  FORMCHECKBOX  No CVA tenderness  FORMCHECKBOX  No Spinal Tenderness _________________________________________________________ Extremities:  FORMCHECKBOX  No cyanosis, clubbing  FORMCHECKBOX  peripheral pulses intact,  FORMCHECKBOX  edema ______________________________________ Musc:  FORMCHECKBOX  No warm or swollen joints  FORMCHECKBOX  Stable ROM in all extremities _____________________________________________ Skin:  FORMCHECKBOX  warm, dry  FORMCHECKBOX  No new rashes/lesions  FORMCHECKBOX  No ulcerations __________________________________________________ Psych :  FORMCHECKBOX  Alert, awake and oriented to person place and time  FORMCHECKBOX  judgment and insight appropriate ______________________ Neuro:  FORMCHECKBOX  Moves all 4 extremities equally  FORMCHECKBOX  DTRs symmetric  FORMCHECKBOX  Strength __/5 _____________________________________ LAD:  FORMCHECKBOX  None in Head  FORMCHECKBOX None in Neck  FORMCHECKBOX  None in Groin  FORMCHECKBOX  None in Axilla ____________________________  FORMCHECKBOX  Labs and Imaging Reviewed  FORMCHECKBOX  Hospital Data Reviewed ASSESSMENT AND PLAN: 1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________ 4. _____________________________________________________________________________________________________ 5. _____________________________________________________________________________________________________ 6. _____________________________________________________________________________________________________ Physician Signature ____________________________ Date: _____________ REVISED 11/15/2018     PAGE  PAGE 3 PAGE  BVjkopq      $ % ( 0 2 J f i j } غز؟yqih*CJaJhCSCJaJh(_CJaJhCJaJh*h cCJaJh*hCJaJh*h CJaJhY]CJaJh 2CJaJh*h 2CJaJh*hM8CJaJhIVCJaJh*hCJaJ h(_5CJ h5CJ h+A5CJ hQ]5CJ&BV j } 2  3 4  x $ m^ `ma$gdf $da$gd$a$gd3gd$a$gd% $a$gd M $$]$a$gd 2 3  ¾º~n]L?h*haJmH (sH (!h*h 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