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Patient Intake History form-men

created by Shelter Lee based on paper forms used at Bayswater Family Practice

HTML icon Patient Intake Form - Male.html — HTML, 10 kB (11016 bytes)

File contents

<html>
<title>Patient Information Form - Men</title>
<head>

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</head>
<body>

<form method="post" action="" name="FormName">

<p class="title">
	Patient Information Form - Men
</p>


<table width="800">
	<tr>
		<td class="heading1"  colspan="2">Patient Demographics:</td>
	</tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="Demographics" class="formtext" style="height:100;"></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Previous MD</td>
		<td class="normaltext"><input class="formtext" name="PrevMD" type="Text"></td>
	</tr>
</table>


<table width="800">
	<tr>
		<td class="heading1" colspan="2">Problem List</td>
	<tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="ProblemList" class="formtext" style="height: 200;" wrap="virtual"></textarea></td>
	</tr>
</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">Past History</td>
	<tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="PMH"  class="formtext" style="height: 200;" wrap="virtual"></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Anesthetic Problems</td>
		<td><input name="AnestheticProblems" class="formtext" type="text"></td>
	</tr>
	<tr>
		<td class="heading2">STDs</td>
		<td><input name="STDs" class="formtext" type="text"></td>
	</tr>
	<tr>
		<td class="heading2">Contraceptions</td>
		<td><input name="Contraceptions" class="formtext" type="text"></td>
	</tr>
	<tr>
		<td class="heading2">Prostate Problems</td>
		<td><input name="ProstateProblems" class="formtext" type="text"></td>
	</tr>
</table>
<table width="800">
	<tr>
		<td class="heading1" colspan="2">Medications</td>
	<tr>
	<tr>
		<td class="normaltext" colspan="2"><textarea name="Meds"  class="formtext" style="height: 200;" wrap="virtual"></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Allergies</td>
		<td><textarea name="Allergies" class="formtext" style="height:20;"></textarea></td>
	</tr>
	<tr>
		<td class="heading2">Adverse Reactions</td>
		<td><textarea name="AdverseReactions" class="formtext" style="height:20;"></textarea></td>
	</tr>

</table>
<table width="800">
	<tr>
		<td class="heading1" colspan="2">Family History</td>
	</tr>
	<tr>
		<td class="normaltext">
			<input name="BP" type="checkbox">BP
			<input name="CVA" type="checkbox">CVA
			<input name="MI" type="checkbox">MI
			<input name="Lipid" type="checkbox">Lipid
			<input name="DM" type="checkbox">DM
			<input name="Thyr" type="checkbox">Thyr
			<input name="Ca" type="checkbox">Ca
			<input name="ProstateCa" type="checkbox">Prostate Ca
			<input name="Glauc" type="checkbox">Glauc
			<input name="GI" type="checkbox">GI
			<input name="GU" type="checkbox">GU
			<input name="MSK" type="checkbox">MSK
			<input name="Resp" type="checkbox">Resp
			<input name="Allegy" type="checkbox">Allergy
			<input name="EtOH" type="checkbox">EtOH
			<input name="Psych" type="checkbox">Psych
			<br>
			<textarea name="FH" class="formtext" style="height:100;"></textarea>
		</td>
	</tr>
</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">Lifestyle</td>
	</tr>
	<tr>
		<td class="heading2">Smoking</td>
		<td class="normaltext">
			<input name="NeverSmoked" type="checkbox" >Never
			<input name="Quit" type="checkbox" >Quit
			<input name="OccasionalSmoke" type="checkbox" >Occas
			<input name="OccasionalSmoke" type="checkbox" >Active
			<input name="CigsPerDay" type="text" class="formtext" style="width:30px;height:20px;" >cig/day
			&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Start:<input name="StartSmoke" class="formtext" style="width:100px; height:20px;">
			&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Quit:<input name="QuitSmoke" class="formtext" style="width:100px; height:20px;">
		</td>
	</tr>
	<tr>
		<td class="heading2">Caffeine</td>
		<td class="normaltext">
			<input name="Caffeine" type="text" class="formtext" style="width:100;">/day
		</td>
	</tr>
	<tr>
		<td class="heading2">Alcohol</td>
		<td class="normaltext">
			<input name="Alcohol" type="text" class="formtext" style="width:100;">/wk
		</td>
	</tr>
	<tr>
		<td class="heading2">Drugs</td>
		<td class="normaltext">
			<input name="IVDU" type="checkbox">IVDU
			<input name="Drugs" type="text" class="formtext" style="width:500;">
		</td>
	</tr>
	<tr>
		<td class="heading2">Diet</td>
		<td class="normaltext"><input name="Diet" type="text" class="formtext"></td>
	</tr>
	<tr>
		<td class="heading2">Fitness</td>
		<td class="normaltext"><input name="Fitness" type="text" class="formtext"></td>
	</tr>
</table>
<table width="800">
	<tr>
		<td class="heading1" colspan="2">Social History</td>
	</tr>
	<tr>
		<td class="heading2">Relationship Status</td>
		<td class="normaltext">
			<input name="Single" type="checkbox">Single
			<input name="Married" type="checkbox">Married
			<input name="CommonLaw" type="checkbox">Common Law
			<input name="Separated" type="checkbox">Separated
			<input name="Divorced" type="checkbox">Divorced
			<input name="Widowed" type="checkbox">Widowed
		</td>
	</tr>
	<tr> 
		<td class="heading2">Partner's Name</td>
		<td class="normaltext"><input name="PartnerName" type="text" class="formtext"></td>
	</tr>
	<tr>
		<td class="heading2">Sexual Partners</td>
		<td class="normaltext">
			<input name="PartnerM" type="checkbox">M 
			<input name="PartnerF" type="checkbox">F 
			<input name="PartnerBoth" type="checkbox">Both 
			<input name="PartnerNone" type="checkbox">None 
		</td>
	</tr>
	<tr>
		<td class="heading2">Sexual Concern</td>
		<td class="normaltext">
			<input name="SexualConcerns" type="text" class="formtext">
		</td>
	</tr>
	<tr>
		<td class="heading2">Assault/Abuse</td>
		<td class="normaltext">
			<input name="AssaultAbuse" type="text" class="formtext">
		</td>
	</tr>
	<tr>
		<td class="heading2">Education</td>
		<td class="normaltext">
			<input name="Education" type="text" class="formtext">
		</td>
	</tr>
	<tr>
		<td class="heading2">Occupation</td>
		<td class="normaltext">
			<input name="Occupation" type="text" class="formtext">
		</td>
	</tr>
</table>

<table width="800">
	<tr>
		<td class="heading1" colspan="2">Immunization History</td>
	</tr>
	<tr> 
		<td class="heading2">Primary Series</td>
		<td class="normaltext"><input name="PrimarySeries" class="formtext" type="text"></td>
	</tr>
	<tr> 
		<td class="heading2">Last Tetanus Toxoid</td>
		<td class="normaltext"><input name="LastTd" class="formtext" type="text"></td>
	</tr>
	<tr> 
		<td class="heading2">Rubella</td>
		<td class="normaltext"><input name="Rubella" class="formtext" type="text"></td>
	</tr>
	<tr> 
		<td class="heading2">Hep A</td>
		<td class="normaltext"><input name="HepA" class="formtext" type="text"></td>
	</tr>
	<tr> 
		<td class="heading2">Hep B</td>
		<td class="normaltext"><input name="HepB" class="formtext" type="text"></td>
	</tr>
	<tr> 
		<td class="heading2">Flu Vaccine</td>
		<td class="normaltext"><input name="FluVaccine" class="formtext" type="text"></td>
	</tr>
	<tr> 
		<td class="heading2">Pneumo 23</td>
		<td class="normaltext"><input name="Pneumo" class="formtext" type="text"></td>
	</tr>
	<tr> 
		<td class="heading2">Varicella Vaccine</td>
		<td class="normaltext">
			<input name="Varicella" class="formtext" type="text" style="height:20px;"><br>
			Has had Chicken Pox: 
				<input name="ChickenPoxYes" type="checkbox">Yes
				<input name="ChickenPoxNo" type="checkbox">No 
				<input name="ChickenPoxUnsure" type="checkbox">Unsure 
		</td>
	</tr>
</table>
<table width="800">
	<tr>
		<td class="heading1" colspan="2">Immunization Record</td>
	</tr>
	<tr class="heading2">
		<td class="heading2">Date/Immunization/Lot Number</td>
		<td class="normaltext"><textarea name="ImmunizationRecords" class="formtext" style="height:200;"></textarea></td>
	</tr>
</table>

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<div name="FunctionButtons" class="DoNotPrint">
<table>
<tr>
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		Subject: <input name="subject" size="40" type="text">
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</tr>
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</form>
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</body></html>



</body>
</html>

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