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1 FOLLOW UP VISIT FORM: SLEEP MEDICINE CENTERS OF WNY TODAY’S DATE: NAME: Date of Birth:_____________________ Primary Care Physician: ____________________________________ May we send reports to them? □ NO □ YES Additional Physician(s) you would like reports sent to: ___________________________________________________________ Pharmacy Name and Phone Number/Address: __________________________________________________________________ Homecare Company (who you use for CPAP or BiPAP/supplies/ oxygen) if you have one: ______________________________ Do you have any changes in insurance, address, or telephone number? I. UPDATE: CHANGES IN MEDICATION □ NO □ YES NO CHANGES SINCE LAST OFFICE VISIT Have there been any changes in your medications since your last visit? No Yes If yes, complete the following: Name of Medication II. UPDATE: Dose (i.e., mgs) How often taken? PAST MEDICAL HISTORY Have there been any changes in your medical condition since your last visit? No Yes If yes, please describe: Have you seen a physician/health care provider since your last visit? No Yes If yes, please complete the following: PROBLEM III. UPDATE: PHYSICIAN/PROVIDER DATE TREATMENT FAMILY HISTORY Have there been any births, deaths or major illnesses affecting your blood relatives since your last visit? No Yes If yes, please describe: IV. UPDATE: SOCIAL HISTORY Have there been any changes in your living arrangement, employment or education since your last visit? No Yes If yes, please describe: SUBSTANCE Caffeine Tobacco Alcohol Other CURRENTLY USE? No Yes No Yes No Yes No Yes TYPE/AMOUNT/FREQUENCY TURN PAGE OVER … HOW LONG? 2 V. UPDATE: REVIEW OF SYSTEMS Indicate whether you have experienced the following symptoms DURING RECENT WEEKS by checking the “no” or “yes” box for each question. CIRCLE the symptom(s) you have experienced when multiple symptoms are listed in a question. Skin rash, sore, excessive bruising or change of a mole Excessive thirst or urination Change in sexual drive or performance Significant headaches Double or blurred vision, cataracts, glaucoma Diminished hearing, dizziness, hoarseness, sinus problem Cough, shortness of breath, wheezing, asthma Coughing up sputum or blood Blackouts or loss of consciousness Chest pain, pressure, rapid or irregular heart beats Awakening at night short of breath Abnormal swelling in legs or feet Pain in calves when you walk Difficulty swallowing, heartburn, nausea, vomiting Significant problems with constipation, diarrhea Blood in bowel movements Difficulty starting urinary stream or completely emptying bladder. Leaking urine Burning or pain when urinating Pain, stiffness or swelling in back, joints or muscles Fever, large lymph nodes At risk for HIV or AIDS Weight loss or gain of more than 10 pounds over 6 months Experiencing an unusually stressful situation Problems falling asleep, staying asleep, sleep apnea, snoring No No No No No No No No No No No No No No No No No No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Endo Endo Neuro/EENT Resp CV GI GU MSK Hem/ID/Lymph General THANK YOU FOR TAKING A MOMENT TO UPDATE YOUR RECORDS. Patient Signature: Date: -------------------- OFFICE USE ONLY: (DO NOT WRITE BELOW THIS LINE) -------------------Vitals: Age: S: O: A: P: Height: Weight: Blood Pressure: / _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Practitioner: DR RS PJ MS KG Dictated (DICT#________________________) ML RESIDENT NAME _______________________________ Not Dictated PMSI Note Complete Discharge Complete