Stella Center Pre-Visit Questionnaire

Step 1 of 7

14%

Contact Information

Name(Required)

First

Email(Required)

Date

MM slash DD slash YYYY

Phone

Weight

Height

DOB

MM slash DD slash YYYY

I. Chief Complaint (Describe your symptoms):

Describe your symptoms

II. History of Present Illness

1. When did the symptoms start:

MM slash DD slash YYYY

When did symptoms start?

Unknown

2. What was the cause of the symptoms?

3. Describe your symptoms:

4. What increases your symptoms?

5. What decreases your symptoms

6. Sleep History:

a. What time do you go to bed?

b. How many hours does it take you to fall asleep?

c. How many times do you wake up at night, and why?

d. How many hours of sleep do you get per night?

e. How many hours of sleep do you require to feel rested?

f. Have you taken sleep medications or natural supplements to help you fall asleep?

Yes

If yes, please list:

g. Do you use alcohol to go to sleep?

Yes

7. Who is your primary care/general doctor? When were they last seen?

Name:

Phone:

Last seen:

MM slash DD slash YYYY

8. Other providers seen:

Name

Specialty

Treatment Provided

Did it help

Click the “+” button to add more entries as needed.

9. Could you be pregnant?

Yes

III. Past History

1. Allergies:

No Know Allergies

Latex

IVP Dye

Iodine

Shellfish

Sulfa

Penicillin

Other

Please list

Click the “+” button to add more entries as needed.

2. Medications For PTSD:

Please list all medications you are currently taking for PTSD (Use reverse if more space needed)

Medication

Dose

Frequency

Date Started (MM/DD/YYYY)

Prescribing Doctor

3. Other Medications:

Please list all other medications you are currently taking (prescription and nonprescription, including aspirin, Tylenol, fish oil, etc. Be sure to include any blood thinners you are taking – plavix, coumadin, etc.) (Use reverse if more space needed)

Medication

Dose

Frequency

Date Started(MM/DD/YYYY)

Prescribing Doctor

4. Previous Medications/Natural Supplements

Click the “+” button to add more entries as needed.

Medication

Effective? (Yes/No)

5. Previous Hospitalizations without surgery

Yes

Include year and physician's name

Date of Hospitalization (MM/DD/YYYY)

Physician's Name

Click the “+” button to add more entries as needed.

6. Past Surgical History

Yes

Include year and physician's name

Date of Hospitalization (MM/DD/YYYY)

Physician's Name

Click the “+” button to add more entries as needed.

Have you ever had surgery on your neck?

Yes

7. Psychiatric Hospitalizations:

Yes

Include year and physician's name

Date of Hospitalization (MM/DD/YYYY)

Physician's Name

Click the “+” button to add more entries as needed.

8. Hospitalization due to suicide attempt:

Yes

Include year and physician's name

Date of Hospitalization (MM/DD/YYYY)

Physician's Name

Click the “+” button to add more entries as needed.

IV. Other History Questions:

1. Family Medical History

Yes

No Problem

Answers should be mom, dad, brother, sister, aunt, uncle, etc.

Diagnosis

Arthritis

Fibromyalgia

Lupus

Multiple Sclerosis

Epilepsy

Depression

Schizophrenia

Alcoholism

Addictive Behavior

Suicidal Ideation

PTSD

High Blood Pressure

Heart Attack

Heart Disease

Diabetes

Bronchial Asthma

Bleeding Disorder

Hepatitis

Thyroid Disorders

Rehab Center

Suicide Attempt

HIV

Cancer

Family Medical History

Diagnosis

Relationship to You

Additional Details

Click the “+” button to add more entries as needed.

2. Social History

A. Smoking:

Do you smoke now?

Yes

If yes, when did you start?

Provide Details Below(Required)

Cigarettes/Cigars/Pipe

Per day?

Click the “+” button to add more entries as needed.

B. Alcohol:

Do you drink alcohol?

Yes

How much?

Have you ever had a problem with alcohol?

Yes

Cirrhosis of Liver

Please explain

C. Caffeinated Drinks:

Do you consume drinks with caffeine?

Yes

If yes, which drinks do you consume? (Select all that apply)

Coffee

Tea

Iced Tea

Colas

D. Illicit Drugs:

Do you use any street drugs?

Yes

Please explain

Do you use marijuana?

Yes

E. Marital Status:

Married

Single

Divorced

Widowed

No. of children:

F. Criminal History:

Have you ever been convicted of a crime?

Yes

If yes, what was the nature of the offense leading to conviction?

How recent was such offense?

G. Work History:

1. Currently at work:

Employed

Full-Time

Part-Time

Self-Employed

Occupation:

What shift do you work:

How many hours/day?

How many hours/week?

Describe job duties:

Hours you spend

standing

sitting

walking

bending

computer work

2. Currently not at work:

Unemployed

Retired

Disability

Other

Specify:

V. Review of Systems:

1. Constitutional Symptoms:

Weight Loss

Weight Gain

Trying to lose weight

Recurrent Fever

General Weakness

Fatigue

Chills

Insomnia

Hypersomnolence

Weight Loss

lbs

during

Weight Gain

lbs

during

2. Neurological

Yes

Select all that apply

Incontinence of urine or stool

Frequent or Recurrent Headaches

Fainting

Blackouts

Stroke

Gait Difficulties

Paralysis

Frequent Falls

Tremors

Neuropathy

Weakness

Seizures

Epilepsy

Polio

Dizzy Spells

Vertigo

Problems with concentration

Lupus

Alzheimer's

Problems with thinking or thought process

Pain with light touch to skin

Problems with memory

Confusion

Multiple Sclerosis

Head Injury

3. Hematologic

Yes

Select all that apply

Blood Transfusion

Bleeding Disorder (Hemophilia)

Anemia (Iron deficiency, Pernicious, Sickel cell)

Easy Bruising

IV Drug Use

Enlarged Lymph Nodes

4. Infectious Disease

Yes

Select all that apply

Hepatitis

Type A

Type B

Type C

HIV

Herpes

Shingles

TB (Tuberculosis)

5. Psychiatric

Yes

Select all that apply

Suicidal Thoughts

Suicide Attempt

Schizophrenia

Alcohol/Drug Abuse

Crying Spells

Mood Swings

Suicide attempt requiring hospitalization

Depressed

Anxious

Shaky

Agitated

Obsessive Compulsive Disorder

Nervousness

Post Traumatic Stress Disorder

Sexual Abuse History

Domestic Violence

Panic Episode

Paranoia

Hallucinations

Admission to detox center

Suicide Attempt- If yes, when was last attempt?

Admission to detox center (if yes, what for?)

Alcohol

Opioids

Other

Please specify

Have you had any previous hospitalizations for psychiatric care or treatment

Yes

Please specify

History of substance abuse or rehab

Yes

6. NSAIDS/Anti-Inflammatory

Yes

List name, frequency, dosage (i.e. advil, Ibuprofen, Celebrex, etc.)

List name

Frequency

Dosage

Click the “+” button to add more entries as needed.

7. Blood Thinners

Yes

List name, frequency, dosage (i.e. Coumadin, Aspirin, Excedrin, Vitamin E, Plavix, Xeralto, garlic, fish oil, etc.)

List name

Frequency

Dosage

Click the “+” button to add more entries as needed.

8. Musculoskeletal

Yes

No Problems

Select all that apply

Muscle Cramps

Stiff Joints

Swelling of Joints

Generalized Arthritis

Rheumatoid Arthritis

Fibromyalgia Syndrome

Osteoporosis

Neck Pain

Upper Back Pain

Middle Back Pain

Lower Back Pain

Heel Spur(s)

Joint Pain

Hardware

Deformity

Limited Range of Motion

Abnormal sound when moving joint

Gout

Difficulty with walking

Pain in feet

Pain with light touch of skin

Cold Upper Extremity(ies)

Cold Lower Extremity(ies)

Painful light touch to skin

Post surgical pain

Other

Pain with light touch of skin- Please Specify

Cold Upper Extremity(ies)

Cold Lower Extremity(ies)

Please Specify

9. Cardiac

Yes

No Problems

Select all that apply

Heart Trouble

Swelling of Feet

High Blood Pressure

Chest Pain

Heart Murmur

Heart Failure

Osteoporosis

Stents

Shortness of breath with walking

Arterial Graft

Pacemaker

Heart Disease

Edema

Palpitations

PND (Paroxysmal Nocturnal Dyspnea)

Blue Extremities

Rheumatic Fever

Heart Attack or other Cardiac Condition

Please Specify

10. Peripheral-Vascular

Yes

No Problems

Select all that apply

Thrombophlebitis (Inflamed Veins)

Poor circulation in arms

Blood clots in arms

Varicose Veins

Poor circulation in legs

Blood clots in legs

Vascular Surgery

Other

Poor circulation in arms

Blood clots in arms

Varicose Veins

Poor circulation in legs

Blood clots in legs

Vascular Surgery

Please Specify

11. Gastrointestinal

Yes

No Problems

Select all that apply

IBS (Irritable Bowel Syndrome)

Crohn's/Ulcerative Cholitis

Constipation

Diarrhea

Chronic use of laxatives

Jaundice (Yellow Eyes)

Eating Disorder (Anorexia, Bulemia, etc)

Heartburn

Melena (Dark Stool)

Frequent Bowel Movements

Change in Bowel Habits

Clay Color Stool

Hemorrhoids

Rectal Discharge

Other

Please Specify

12. Endocrine

Yes

No Problems

Select all that apply

Diabetes

Hot/Cold Tolerance

Excessive Sweating

Polydipsia (Increased Thirst)

Polyphagia (Increased Hunger)

Infertility

Thyroid Disorder

Other

Please Specify

Diabetes- If yes, do you take insulin

Yes

13. Respiratory

Yes

No Problems

Select all that apply

Cough

Sputum

Hemoptysis (Coughing up blood)

Wheezing

Asthma

Emphysema

Bronchitis

Pneumonia

Pleurisy

Sleep Apnea

CPAP at night

COPD

14. Other

Please specify

Treatment Goal(s):

Certification:

I certify that I have answered truthfully all the questions, and have not knowingly withheld any information concerning any of the above problems, either past or resent.

Certification:(Required)

I certify that I have answered truthfully all the questions, and have not knowingly withheld any information concerning any of the above problems, either past or resent.

Patient Signature: (Type your full name)

Date

MM slash DD slash YYYY

Parent Signature if Minor:(Type your full name)

Transcriber:

Reviewing Provider(s):