Dr. H. Robert Silverstein MD FACC

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Available Forms

New Patient Form

PATIENT

NAME OF PATIENT (First, Middle, Last) *

SOCIAL SECURITY NUMBER

DATE OF BIRTH (Mo/Day/Year) *

FEMALE

MALE

ADDRESS (No and Street, City, State, Zip Code *

TELEPHONE (Home) *

TELEPHONE (Cell) *

MARITAL STATUS *

BIRTHPLACE *

City, State, Country

RELIGION

Optional

NUMBER OF CHILDREN & AGES *

EDUCATION

Select Appropriate

OCCUPATION *

NAME OF EMPLOYER

NEAREST RELATIVE OR FRIEND TO BE REACHED IN CASE OF EMERGENCY *

Give Name, Relationship, Address, & Telephone #

REFERRING PHYSICIAN

Name and Specialty

IF NO REFERRING PHYSICIAN, GIVE NAME OF REFERRING PERSON

PHARMACY *

Name & Address

REMARKS

INSURANCE *

INSURER NAME, ID NUMBER, GROUP NUMBER

INSTRUCTIONS: Please check appropriate answers for each item. (All the items must be answered.)

PAST MEDICAL HISTORY *

Select all that apply

ALLERGY HISTORY (TYPE) *

ECZEMA

ASTHMA

HAY FEVER

HIVES

TRUE MIGRAINE

ALLERGIC PENICILLIN

ALLERGIC TO OTHER DRUGS

OTHER

Select all that apply

CURRENT DRUGS & DOSAGES *

If taking any medicines, list above, include aspirin, cough medicine, headache remedies, sleeping pills, and ALL prescription pills.

FAMILY HISTORY

MOTHER *

Age (If deceased, cause of death)

FATHER *

Age (If deceased, cause of death)

NUMBER OF BROTHERS *

NUMBER OF SISTERS *

PROVIDE THE NUMBER OF FAMILY BLOOD RELATIVES (Parents, Grandparents, Siblings, Children or Aunts, Uncles, Nieces, Nephews, etc.) WHO HAVE HAD THE FOLLOWING ILLNESSES OR INCIDENTS.

HIGH BLOOD PRESSURE

YES

Number of relatives

HEART DISEASE *

YES

Number of relatives

HEART SURGERY *

YES

Number of Relatives

MURMUR *

YES

Number of Relatives

SUDDEN UNEXPECTED DEATH *

YES

Number of Relatives

STROKE *

YES

Number of Relatives

DEATH BEFORE AGE 60 *

YES

Number of Relatives

EMPHYSEMA *

YES

Number of Relatives

ASTHMA *

YES

Number of Relatives

ALLERGIES *

YES

Number of Relatives

DIABETES *

YES

NIO

Number of Relatives

CANCER *

YES

Number of Relatives

ALCOHOLISM *

YES

Number of Relatives

TB *

YES

Number of Relatives

KIDNEY DISEASE *

YES

Number of Relatives

THYROID TROUBLE *

YES

Number of Relatives

RHEUMATOID ARTHRITIS *

YES

Number of Relatives

OVERWEIGHT *

YES

Number of Relatives

ADDICTION *

YES

Number of Relatives

SUICIDE *

YES

Number of Relatives

HOSPITALIZATIONS

LIST ALL MEDICAL & SURGICAL ADMISSION *

INCLUDE: Date (Mo/Year), Name of Hospital, Name of Doctor, Length, and Diagnosis/Treatment

SURGERY

Please select appropriate answers and give age when surgery was performed.

HEART *

YES

Age

LEG OR NECK BYPASS *

YES

Age

ANEURYSM *

YES

Age

LUNGS *

YES

Age

KIDNEY *

YES

Age

TRANSFUSIONS *

YES

Age

CANCER *

YES

Age

TONSILS

YES

Age

ADENOID *

YES

Age

GALLBLADDER *

YES

Age

HERNIA *

YES

Age, Right or Left

STOMACH *

YES

Age

DUODENUM *

YES

Age

ULCER

YES

Age

APPENDIX *

YES

Age

HEMORRHOIDS *

YES

Age

BOWEL *

YES

Age

PREGNANCIES *

YES

Age

DELIVERIES *

YES

Age

D & C's *

YES

Age

UTERUS *

YES

Age

CERVIX *

YES

Age

OVARIES *

YES

Age

BREAST *

YES

Age, Right or Left

PROSTATE *

YES

FRACTURES *

YES

Age, Specify

INJURIES *

YES

Age, Specify

OTHERS *

YES

Specify

YOUR PERSONAL HISTORY

Please answer all the questions below.

VARICOSE VEINS (Not Blotches) *

YES

CLOTS IN THE LEGS *

YES

PHLEBITIS *

YES

WHEEZE *

YES

MORNING COUGH *

YES

SINUS TROUBLE *

YES

HOARSENESS *

YES

FAINTING *

YES

CONVULSIONS *

YES

FAINTNESS IN CROWDED LOCATIONS *

YES

FAINTNESS IN POSITION CHANGE *

YES

FAINTNESS IN CHURCH *

YES

HIATUS HERNIA *

YES

GALL STONES *

YES

HEARTBURN *

YES

NAUSEA *

YES

VOMITING *

YES

STOMACH ULCER *

YES

BLACK STOOL *

YES

BELLY PAIN *

YES

BLOOD IN STOOL *

YES

DATE OF LAST RECTAL EXAM

DATE OF LAST SIGMOIDOSCOPY

HEMORRHOIDS *

YES

NIGHT SWEATS *

YES

WEIGHT CHANGE IN 6 MONTHS *

YES

ARE YOU TRIM? *

YES

ARE YOU OVER WEIGHT? *

YES

WHAT % OF YOUR DIET CONSISTS OF VEGETABLES, FRUITS, & GRAINS? *

WHAT % OF YOUR DIET IS RED MEAT, CHEESE, OIL, MARGARINE, OR BUTTER? *

IS YOUR WILLPOWER ADEQUATE? *

YES

DO YOU SIT IN THE SAME CHAIR FOR ALL EATING AT HOME? *

YES

DO YOU EAT ANYTHING AFTER 8:30 PM? *

YES

SEVERE HEADACHES ON: *

THYROID *

YES

TROUBLE STARTING URINE *

YES

TROUBLE STOPPING URINE *

YES

FREQUENT URINE *

YES

BURNING URINE *

YES

BLOOD IN URINE *

YES

URINE INFECTIONS *

YES

NEPHRITIS *

YES

SEVERE JOINT PAINS *

YES

SEVERE BACK PAIN *

YES

SEVERE INFECTIONS OR BOILS *

YES

BIRTH CONTROL PILL OR ESTROGEN *

YES

MENOPAUSE *

YES

If yes, describe age, any past treatment, any present treatment above.

X-RAY *

STOMACH

BACK

COLON

KIDNEY

SPINE

MAMMOGRAM *

YES

CT SCAN *

YES

MRI *

YES

FLEXIBLE SIGMOIDOSCOPY *

YES

OPTIONAL

You do not have to answer the following questions.

GONORRHEA *

YES

SYPHILIS *

YES

UNABLE TO HAVE ERECTION *

YES

UNABLE TO HAVE CHILDREN *

YES

BREAST LUMPS *

YES

BLEEDING BETWEEN PERIODS *

YES

BLEEDING SINCE MENOPAUSE *

YES

IUD *

YES

DATE OF LAST PAP TEST

HOT FLASHES *

YES

TROUBLE SLEEPING *

YES

FEEL DEPRESSED *

YES

DISTURBING FAMILY PROBLEMS *

YES

SEXUAL DIFFICULTY *

YES

SEEN A PSYCHIATRIST *

YES

NERVOUS BREAKDOWN *

YES

DRUG POISONING *

YES

NIGHTMARES *

YES

DO YOU FIND IT HARD TO MAKE A DECISION INVOLVING SOME UNKNOWN? *

YES

ARE YOU SHY? *

YES

ARE YOU SENSITIVE? *

YES

BITE YOUR NAILS? *

YES

TROUBLE WALKING *

YES

TREMOR *

YES

DISCUSS ANY MEDICAL INFORMATION OR CONDITIONS NOT COVERED ABOVE.

CARDIAC HISTORY

Please select if you have any of the following conditions.

PLEASE DISCUSS THE FOLLOWING QUESTIONS IN THE SPACE BELOW.

Be as specific as possible. Starting at the beginning.

What is your major problem for which I am seeing you? *

What are your expectations of me? *

In what ways do you expect to participate in your increasing your own health and well being? *

* Required field