Download FOLLOW UP VISIT FORM: SLEEP MEDICINE CENTERS OF WNY

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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?
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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
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 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