Jack
Vitenson, M.D. Sergey
LAST NAME ___________________ FIRST NAME
_________________ MIDDLE _____________
Today’s Date _________ Date
of Birth ________________ Telephone #
_______________
What is the main reason for
your visit today? (Please describe your
problem in detail)
______________________________________________________________________________________________________________________________________________________________________________
|
Location of problem Abdomen Back/Kidney Bladder Genitals Urine
Infertility Other_____________________________________________ __________________________________________________ |
Is anything else occurring
at the same time? Yes No
If yes, please explain Nausea Vomiting Fever Other |
||
|
When did you first notice
the problem? Few days ago Few weeks ago Months ago Other |
Does the problem interfere
with your normal activity? |
||
|
Does anything help or make
the problem worse? Moving around Lifting /
Straining Eating / Drinking Others |
On a scale of 1-10, with 10
being he most severe, circle the number that best describes the problem. 1 2 3
4 5 6
7 8 9
10 |
||
|
How long does the problem
last? 30-minutes, 1-hour,
etc… It is always there? |
Is there pain? Yes No (If
yes, please describe) Dull Sharp Comes and goes Always there Other____________________________________ |
||
|
Physician Use only
# ANS Service 1-3
1 or 2 4+ 3
- 5 |
|||
Please list any personal
serious illnesses.
(Example: Diabetes, heart
disease, tuberculosis, cancer, etc)
Illness Date
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
Please list any personal
surgeries and when they occurred.
(Example: Appendectomy, etc)
Illness Date
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
Are you on any
Medications? Y/N
Medication Name Dose How Often?
___________________ ____ _______________
___________________ ____ _______________
______________ _____ ____ _______________
______________ _____ ____ _______________
______________ _____ ____ _______________
______________ _____ ____ _______________
______________ _____ ____ _______________
______________ _____ ____ _______________
Do you have any
Allergies? Y/N
___________________________________________
Do you smoke? Yes/No
If
yes, How much? How
Long?
Do you drink alcohol? Yes/No
If
yes, How much? How
Long?
Please list all serious illnesses in your immediate
family. (Example:
Prostate Cancer, Kidney cancer, Kidney stones)
# ANS Service 0 1
or 2 1-2 3 3 4
or 5
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________