Letter of Explanation

Transcription

1 Letter of Explanation We would like to take a moment to thank you, our valued customer, for scheduling your physical exam with us. As you know, Health by Design strives to provide you with the best care combined with state-of-the-art technology, to give you the best overall picture of your health and wellbeing. Pursuant to that goal, it is important for our patients to realize that we do not overbook our appointments. From the moment that you book an appointment with us, we have set aside 2-3 hours of your doctor s time specifically for you. In addition, our medical support staff is informed of your needs in advance in the hope that we can provide the care you need in the most efficient manner possible. Many of our patients have noticed the change in our Welcome Letter and the new phrase broken appointment fee. We want to reassure you that customer service is our first priority; however, it is difficult to deal with broken appointments when we absolutely do not overbook our time like other physician practices. We request that you inform us at least 3 days in advance if you will be unable to make an appointment with your assigned physician. However, sometimes things come up and you might have to cancel your appointment with far less of a notice. We understand circumstances might be beyond your control. At this point we can provide our valued customers with 2 options: 1. Request to be added to our waiting list. When you call to cancel your appointment, our receptionist will set up a time for you to come in and complete your paperwork and lab draws as soon as possible. When an appointment slot becomes available, we will contact you and see if it fits within your schedule. There is no additional charge associated with this option. 2. Request to pay the broken appointment fee and reschedule your appointment at your convenience. It is our hope that this new procedure will help keep our exam costs down while assisting you with any time issues that may arise. If you have any additional questions regarding our new broken appointment fee, please contact us at

2 RETURNING PATIENT MEDICAL QUESTIONNAIRE I DATE: DATE OF NAME: AGE: BIRTH: / / SEX: (First) (Middle Initial) (Last) (Month) (Day) (Year) MAILING ADDRESS: (Street Address) (City) (State) (Zip) PHONE: (Home) (Cell Phone) (Work Phone) OCCUPATION: _ EMPLOYER: EMPLOYEE#: INSURANCE CARRIER: PERSONAL PHYSICIANS: (List Names) Family Practitioner: Internist: OB/GYN: Cardiologist: Orthopedist: Other Specialists: I. GOALS: Briefly list your goals for taking part in the Health by Design Program. Preferred Pharmacy: Phone/Fax EMERGENCY CONTACT INFORMATION: Relationship_ MARITAL STATUS: What are your most important concerns regarding your health? II. MEDICAL HISTORY: A. STATE OF HEALTH: Estimate your current state of health. Excellent Good Fair Poor B. RECENT ILLNESS: Have you recently (past 1-2 weeks) been ill? Yes No If yes, explain: C. MEDICAL CHANGES: Since last HBD examination 1. Illnesses: (Please explain) 2. Physician Visits: (Please explain) 3. Hospitalization; (Please explain)

3 D. CURRENT MEDICATIONS: (Include vitamin preparations, sleeping medicine, birth control pills, over the counter medications, and other medicines). E. BLOOD DONATIONS: Do you donate blood? Yes No If yes, how often? Date of most recent donation: F. ALLERGIES: Please list any drug allergies you have and the type of reaction to the medication. Please list any external environmental allergies you have. Have you been evaluated by an allergist? Yes No Have you taken or do you take allergy shots? Yes No Have you had asthma? Yes No G. IMMUNIZATIONS Have you had diphtheria & tetanus boosters in the last 10 years? Yes No Have you had a flu vaccine this year? Yes No If you are 60 years old or older, have you had a shingles vaccine? Yes No If you are 60 years old or older, have you had a pneumococcal vaccine? Yes No III. IV. FAMILY HISTORY: Have there been any changes in family history since your last HBD exam. FATHER MOTHER BROTHERS SISTERS CHILDREN _ SOCIAL HISTORY AND LIFESTYLE: A. MARITAL STATUS: Single Married Widowed Divorced If married, how many years? Spouse s Occupation: Spouse s Name: Health status of spouse: Good If not, please comment B. EMPLOYMENT: Changes in employment since last HBD exam: How many hours per week do you work? _ Is your job stressful? If yes, explain: How many people (if any) do you supervise? V. HEALTH SCREENING: Have you participated in any of the following health screening procedures? If yes, give most recent. Flexible sigmoidoscope Yes No If yes, date: Colonoscopy Yes No If yes, date: Stool exam for blood Yes No If yes, date: Cardiovascular screening Yes No If yes, how often: _ If yes, what type of screening? Women Pap smear Yes No If yes, date: Mammogram Yes No If yes, date: Breast self-examination Yes No If yes, how often? _ Men Testicular self-examination Yes No If yes,_ how often? Have any abnormalities been noted in any of these procedures? Yes No If yes, explain:

4 VI. VII. VIII. IX. CHEMICAL EXPOSURE: A. SMOKING: Do you currently smoke tobacco or use smokeless tobacco products? Yes No If yes, Cigarettes packs per day Pipe bowls per day Cigars per day Other If yes, how many years have you smoked? Have you used tobacco before and quit? Yes No If yes, when did you quit? How long did you smoke? How many packs/day? If currently smoking/using tobacco, would you like assistance in quitting? Yes No B. ALCOHOL: Do you drink alcoholic beverages? Yes No If yes, Beer # of servings/week (); Liquor # of servings/week (2 oz) Wine # of servings of wine/week (4.5 oz) C. CAFFEINE: How many cups of coffee, tea and cola (with caffeine) do you drink daily? EXERCISE PROGRAM: 1. Do you have a regular exercise program? Yes No 2. Have you ever had an exercise stress test? Yes No When? _ Please list any abnormal findings: 3. If you have a regular exercise program, please describe below: HOW LONG HAVE YOU BEEN TYPE FREQUENCY TIME/DISTANCE DOING THIS ACTIVITY? What type of prescribed exercise would you prefer to do? Walking Swimming Indoor Treadmill Jogging Rowing Jump Rope Cycling (outdoors) Tennis Mini-Trampoline Cycling (stationary) Racquetball/Handball Weights Other: _ How physically fit do you feel at the present time? Below Average Average Above Average Terrific STRESS AND LIFE SATISFACTION When you experience stress, is it mainly from: Your job Your family Both Explain: SLEEP HISTORY:* The following questions are used to screen for sleep apnea: 1. Do you snore? Yes No 2. Does your bed partner or sleep observer complain about your snoring being broken, audible gasps, chokes, or snorts Yes No 3. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. 0 = would never doze 1 = slight chance 2 = moderate chance of dozing 3 = high chance of dozing

5 SITUATION Sitting and reading Watching TV Sitting inactive in a public place (e.g., a theater or meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone In a car while stopped for a few minutes in traffic TOTAL* CHANCE OF DOZING * If you score 8 points or more in question #3, you have a significant daytime sleepiness and impairment. If questions #1 and/or #3 are also positive, it is very likely that you may be suffering from obstructive sleep apnea syndrome and further medical evaluation is necessary. X. REVIEW OF SYSTEMS: Do you currently have any of the following? Condition Yes No Remarks Weight loss or gain Unexplained fever Excessive fatigue or weakness Changes in your skin (lumps, rashes, sores) Changes in vision Blurred or double vision Wear glasses/contacts Glaucoma Eye pain Spots or lines in your vision Hearing problems Ringing in ears Dizziness Earache or ear discharge Nasal congestion Hay fever/allergies Nosebleeds Bleeding gums Sore tongue, mouth Hoarseness Neck lumps or pain Breast lump, pain, nipple discharge Cough Coughing up blood Wheezing Persistent cough at night Recurrent respiratory infection Emphysema Tuberculosis or exposure to TB Heart trouble High blood pressure Rheumatic fever Heart murmur Shortness-of-breath Shortness-of-breath when lying down

6 Condition Yes No Remarks Swelling Chest pain, tightness, heaviness Palpitation, irregular heart beat Past heart evaluation Trouble swallowing Persistent nausea or vomiting Changes in appetite Vomiting blood Indigestion/heartburn Change in bowel habits Black or blood stools Constipation or diarrhea Excessive gas Hemorrhoids Jaundice Liver problems Gallbladder disease Abdominal pain Frequent urination Difficult or painful urination Blood in the urine Reduced force of stream Kidney stones Frequent (>1) urination at night Leg pain with walking Leg cramps Leg tenderness, redness, warmth Muscle or joint pain, swelling Back pain Headaches Fainting Seizures Paralysis Numbness, tingling Tremors Anemia Easy bruising or bleeding Heat or cold intolerance Excessive thirst or urination Nervousness Depression Thoughts of suicide Moodiness Memory Loss Do you still feel tired after sleeping? Circle # of hours you sleep at night: Difficulty sleeping Crying spells Loss of interest in activities Change in sexual frequency/desire MEN: Penile discharge Testicular lump or pain

7 Hernia Problems with erections WOMEN: Irregular or heavy menstrual periods Bleeding between periods Menopausal symptoms Vaginal discharge Pain/difficulty with intercourse Condition Yes No Remarks WOMEN: # of pregnancies Last menstrual period: Deliveries Age at menopause C-section NOTES: Miscarriages/Abortions

8 Name Age Sex Ht Wt Exercise (circle one) Light Med Heavy NUTRITIONAL ANALYSIS 1. For each food item listed, put down how many servings you eat, either per day, per week, or per month. Be as accurate as possible. Pay special attention to the serving size of each food item. When your portion is different from the one given, adjust the number of servings you eat accordingly. 2. Put numbers only in either the per day, per week, or per month column. No check marks. If you do not eat the food at all, put a zero. Use whole numbers only, no fractions. 3. Include all foods that you eat at least once per month. 4. Remember to include all meals and snacks, at home or out. Include what you put on foods such as salad dressing, sugar, jam, etc. SAMPLE QUESTIONS: 1. Day Week Month Serving 1 Milk, low-fat To calculate, take your usual serving size and compare it to the one listed. If you have twice as much, you would then double the number of servings entered in the day, week, or month box. For example, if you have low-fat milk once per day, and your serving is, then enter a 1 in the box for per day. 2. Day Week Month Serving 9 2 each Cookies (chocolate chip, oatmeal, peanut butter, etc.) Let us say you eat cookies three times per week. However, instead of 2 cookies three times per week you have 6 cookies three times per week. This is 6 X 3 = 18 total cookies per week. Since the standard serving size is 2, you would divide 18 by 2 = 9 two-cookie servings per week. You would enter a 9 in the box per week. How often do you eat (or drink) the following: Day Week Month Serving 1 mod 1/2 ea 4-6 ea 4 ea 2 ea 7 ea 3 ea 3/4 cup 1/4 cup Breads/Cereals/Grain Products Whole wheat, rye, or mixed grain bread or roll White, sourdough, or French bread Hamburger bun, English muffin, bagel, pita bread Muffin (corn, blueberry, bran) Whole grain crackers (Triscuit, Rye Crisp, etc.) Refined crackers (Saltines, cheese, Ritz, etc.) Graham crackers Animal crackers Corn tortilla Flour tortilla Croissant Pancakes Waffle, 7 diameter Whole grain cooked cereal (oatmeal, rolled wheat, etc.) Refined/instant cooked cereal (Cream of rice/cream of wheat/ instant oatmeal, etc.) Cold cereals, no sugar (Shredded Wheat, Cheerios, etc.) Grapenuts Day Week Month Serving 1/4 cup 3/4 cup 3/4 cup Bran type cereals (Raisin Bran, Bran Flakes) All Bran, 100% Bran, etc. Sweetened cold cereals (Frosted Flakes, Sugar Smacks, etc.) Granola cereal Granola bar Brown rice, cooked White rice, cooked Chinese fried rice or Spanish rice Pasta/macaroni, spaghetti, noodles Macaroni and cheese Stuffing Non-fat milk or buttermilk Low-fat (2%) milk Whole milk Milk & Yogurt Chocolate low-fat milk Yogurt, plain - non-fat/low-fat Yogurt, low-fat with fruit

9 Day Week Month Serving 3 ea 15 ea 3/4 cup 1/2 ea 2 Tbsp Starchy vegetables (corn, peas, mixed veg., etc.) Cooked veggies (green beans, beets, cauliflower, squash, etc.) White potatoes: baked, boiled, mashed Sweet potatoes or yams Winter squash (acorn, bluenut, Hubbard) Legumes (lentils, pinto beans, navy beans, etc.), cooked How often are the veggies listed 1 serv above seasoned with fat (butter, margarine, bacon, etc.)? Vegetable casserole (green bean, scalloped potatoes, spinach souffle, etc.) Fried vegetables Sm order French fries, onion rings Refried beans Potato salad Fruits Apple, peach, nectarine, pear Apricots, plums Cherries Pineapple, berries Grapes Banana Orange, tangerine Grapefruit Melon (canteloupe, watermelon, etc.) Dried fruits (raisins, dates, prunes, apricots) Unsweetened fruit, canned or frozen Sweetened fruit, canned or frozen Unsweetened orange or grapefruit juice Other unsweetened juice (apple, grape, pineapple) Sweetened juices or nectars (cranberry, pear, prune, etc.) Vegetables Green salads (lettuce, celery, peppers, etc.) Dark green leafy vegetables (broccoli, spinach, cabbage, etc.) Carrot, raw Carrots, cooked Tomatoes, fresh, medium Tomato or V-8 juice Day Week Month Serving ice 1cup 1cup 1cup 1 serv 7 oz 1 pc 7 oz 1 oz 2 ea 2 ea 1/4 cup 1 oz 1 oz 1 pkg 1 pkg Fast Foods/Combination Foods Pizza Hamburger Beef Taco Enchilada Tamale Breakfast Taco Chili or beef vegetable stew Lasagna or spaghetti w/meat sauce Chicken casserole (chicken divan, chicken & dumplings, etc.) Chinese stir fry meat/veg entree (pepper steak, chop suey, moo goo pan, etc.) Note: This does not include items like lemon chicken, sweet & sour pork, etc. These are included under fried meats. Meat salad (tuna, chicken, crab, or ham salad) Protein Foods Beef (roast, steak, ground, etc.) Pork (chops, roasts, ham, etc.) Lamb (chops, roasts, etc.) Chicken and turkey Fish (fresh or frozen, no breading) (trout, sole, cod, salmon, etc.) Fish, canned w/oil (tuna, sardines) Tuna, canned, water-packed Shellfish (shrimp, scallops, lobster, crab, etc.) Chicken-fried steak Fried chicken Fried fish Liver, beef Lunch meats (bologna, salami, etc.) Hot dogs Sausage links Egg, large Egg whites Egg substitute Cheese (cheddar, American, Swiss, Monterrey Jack, etc.) Cheese, lower fat (mozzarella, skim milk, ricotta) Cottage cheese HMR 70 supplement HMR 500 supplement

10 Day Week Month Serving Fats & Oils 127 Day Week Month Serving Vegetable oil (corn, safflower, olive, etc.) ea Solid fat (shortening, lard, margarine, butter) ea Olives pc 1/4 ea Avocado 115 1/4 cup Guacamole 116 Mayonnaise 117 Regular salad dressing 118 Low-calorie salad dressing 119 Sour cream or dip (buttermilk, onion, clam, etc.) 120 Cream cheese 121 Half & Half, light cream, non-dairy coffee creamer 122 Heavy whipping cream sl Bacon 124 Beverages /2 oz Lemonade, punch, Kool-aid /2 oz 4 oz 4 oz 1-1/2 oz Cola-type soda w/sugar (Coke, Pepsi, etc.) Diet soda, cola-type Non-cola soda w/sugar Diet soda, non-cola Regular coffee or tea Decaffeinated or non-decaffeinated beverages (Sanka, herb tea, etc.) Hot chocolate or cocoa Beer Lite beer Wine, sweet or dessert (sherry, muscatel, etc.) Wine, dry or table (red, white, champagne) Liquor (rum, whiskey, vodka, brandy, etc.) cups 2 cups Desserts and Sweets Cookies (Choc. chip, oatmeal, peanut butter) Doughnut or sweet roll Cake Angel food cake Cheesecake Cream pie Fruit pie Pecan pie Jello/popsicle Pudding or custard Ice cream Ice milk, frozen yogurt Sherbet Candy, chocolate, M&Ms Hard candy, gum drops Milkshake Miscellaneous Popcorn, popped, no oil Popcorn, popped w/oil 1 oz Pretzels 1 oz Potato chips, corn chips, (10-15) tortilla chips Nuts, seeds (peanuts, cashews, 1 oz sunflower seeds, pecans, almonds, etc.) Peanut butter, nut butter Catsup, mustard, BBQ sauce, chili sauce, steak sauce Soy sauce, teriyaki sauce, Worcestershire sauce 1/4 cup Gravy, white sauce Tomato sauce, 1/4 cup Spaghetti sauce, marinara 1/2 Tbsp Pickles, pickle relish Soup (cream style) Soup (vegetable or noodle type) Sugar, honey, jam, jelly, syrups