Page 1 of 3
Riad Adoumie, M.D., FRCS (C), FACS, RVT
Rashaan Ali-Jones, M.D., FACS
Neil H. Bhayani, M.D., MHS, FACS
James E. Camel, M.S., M.D., FACS
Melanie H. Friedlander, M.D., FACS
Amir Kaviani, M.D., FACS
Stanley R. Klein, M.D., FACS
Albert Y. Lam, M.D., FACS
Michael H. Li, M.D.
Megan R. Linnebur, M.D.
Roman A. Litwinski, M.D., FACS
Catherine A. Madorin, M.D., FACS
Vijay Muraliraj, M.D., FACS
Son X. Nguyen, M.D., FACS
Houman Saedi, M.D., FACS
Houman Solomon, M.S., M.D., FASMBS, FACS
Aileen M. Takahashi, M.D., FACS
Patient Health Questionnaire
Name:_____________________________________ DOB:_________________ Date:_____________
Age:________ Height:________ Weight:__________ Reason for visit: _________________________
Referring Provider:_______________________________ Phone number: _________________________
Primary Care Provider:____________________________ Phone number: _________________________
Cardiologist: ____________________________________ Phone number: _________________________
Occupation: ____________________________________________________________________________
Have you had any of the following? Please check the appropriate boxes below.
High Blood Pressure
Acute Myocardial Infarction
A-Fib
Coronary Artery Disease
Stroke
Venous Thrombosis (DVT)
Cancer Type:____________
High Cholesterol
Diabetes Mellitus
Thyroid Disorder Type:______
Yes
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No
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Esophageal Reflux
Asthma
COPD
Sleep Apnea
Osteoporosis
Renal Failure
Blood Disorder Type: ____________
HIV Infection
Hepatitis
Other _________________________
Yes
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No
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Please list any surgeries, significant illnesses, injuries or hospitalizations, starting with the earliest date:
Year Operation Comments
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Page 2 of 3
Riad Adoumie, M.D., FRCS (C), FACS, RVT
Rashaan Ali-Jones, M.D., FACS
Neil H. Bhayani, M.D., MHS, FACS
James E. Camel, M.S., M.D., FACS
Melanie H. Friedlander, M.D., FACS
Amir Kaviani, M.D., FACS
Stanley R. Klein, M.D., FACS
Albert Y. Lam, M.D., FACS
Michael H. Li, M.D.
Megan R. Linnebur, M.D.
Roman A. Litwinski, M.D., FACS
Catherine A. Madorin, M.D., FACS
Vijay Muraliraj, M.D., FACS
Son X. Nguyen, M.D., FACS
Houman Saedi, M.D., FACS
Houman Solomon, M.S., M.D., FASMBS, FACS
Aileen M. Takahashi, M.D., FACS
Name: ______________________________________ DOB:______________________ Date: _______________________
Do you currently have any of the following:
Recent weight change
Fever
Chills
Skin lesions
Lump or swelling of neck
Hoarseness
Chest pain or discomfort
Shortness of breath
Yes
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No
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Difficult swallowing
Abdominal pain
Bowel/bladder changes
Constipation
Rectal bleeding
Pain during urination
Muscle aches
Motor disturbances
Yes
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No
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History of family diseases. (If other than immediate family, please indicate “M” for Maternal or “P” for Paternal.
Cancer □ Y □ N Type: ____________________ Relationship: _______________________
Psychological □ Y □ N Type: ____________________ Relationship: _______________________
Obesity □ Y □ N Relationship: ________________
Diabetes □ Y □ N Relationship: ________________
Thyroid disease □ Y □ N Relationship: ________________
Stroke □ Y □ N Relationship: ________________
Pulmonary disease □ Y □ N Relationship: ________________
Kidney disease □ Y □ N Relationship: ________________
Gallstones □ Y □ N Relationship: ________________
Inflammatory bowel disease □ Y □ N Relationship: ________________
Heart disease □ Y □ N Relationship: ________________
Have you ever had a problem with anesthesia? (If yes, please explain.)
__________________________________________________________________________________________________________
______________________________________________________________________________________________________
Please list any allergies including those to drugs, latex, adhesive tape, food, etc., and include your reaction: -
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
____________________________________________________________________________________________________
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Page 3 of 3
Riad Adoumie, M.D., FRCS (C), FACS, RVT
Rashaan Ali-Jones, M.D., FACS
Neil H. Bhayani, M.D., MHS, FACS
James E. Camel, M.S., M.D., FACS
Melanie H. Friedlander, M.D., FACS
Amir Kaviani, M.D., FACS
Stanley R. Klein, M.D., FACS
Albert Y. Lam, M.D., FACS
Michael H. Li, M.D.
Megan R. Linnebur, M.D.
Roman A. Litwinski, M.D., FACS
Catherine A. Madorin, M.D., FACS
Vijay Muraliraj, M.D., FACS
Son X. Nguyen, M.D., FACS
Houman Saedi, M.D., FACS
Houman Solomon, M.S., M.D., FASMBS, FACS
Aileen M. Takahashi, M.D., FACS
Name: ______________________________________ DOB:______________________ Date: _______________________
Do you currently smoke? Y □ N □ Packs per day? _____ Number of years? _____
Former smoker: Y □ N □ Year you quit: ________
Other tobacco use? Y □ N □ Type: _______________
Alcohol use? Y □ N □ Frequency? ___________
Recreation drug use? Y □ N □ Type/frequency? _________________________
When was your last flu vaccination? ____________________________________________
(Patients ages 50-75)
When was your last colonoscopy? ___________________________
(Female patients age 40 or older)
When was your last mammogram? __________________________
(All patients age 65 or older)
Have you ever received a pneumonia vaccination? Y □ N □ Approximate date: _____________
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