Diagnostic studies. PLEASE LIST THE APPROXIMATE DATE OF TEST, THE NAME OF THE FACILITY WHERE THE TEST WAS PERFORMED, THE NAME OF THE ORDERING PHYSICIAN AND THE RESULTS, IF KNOWN. TEST DATE FACILITY PHYSICIAN RESULTS EMG ▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Patient Name : Account #: MR # : Date : Headaches Trouble with hearing Trouble with eyesight Nasal discharge Hay Fever, frequent sneezing Sinus trouble, post nasal drip Hoarseness Ulcer of tongue or mouth Trouble with gums or teeth Sore throat Asthma, wheezing Cough Cough up blood Tuberculosis Shortness of breath High blood pressure Chest pain Irregular beat or palpitation of heart Increased thirst, hunger Sudden weight change Sensitive to heat/cold Change in skin, body hair Change in sex drive Rash Tumor on skin Frequency urgency or pain with urination Passed blood or kidney stone Trouble starting or stopping of urinary stream Trouble swallowing Abdominal pain, nausea, vomiting Acid Reflux (“Heartburn”) Stomach ulcer/Duodenal ulcer Black bowel movements Diarrhea Constipation Hemorrhoids or rectal itching Low back pain Joint pain Arthritis Neck pain Backache Balance prolems Numbness or tingling anywhere Weakness Trouble walking Problems with sleep Dizziness Depression Fatigue Anemia or difficulty with bleeding Sexual problems Awaken at night with shortness of breath Please check any of the following below that you have had or currently have a problem with: Alcohol Acquired Brain Injury ALS Asthma Bladder Pain / Spasms Blood Clots Blood in Stool Blood in Urine Cerebral Palsy Cigarettes Current Pregnancy Diabetes Drugs Dysreflexia Frequent UTI Gynecological Problems Hay Fever / Allergies High Blood Pressure HIV (or AIDS) Impaction Kidney Failure Multiple Sclerosis Neurogenic Bladder Neurogenic Bowel Paraplegia Pneumonia Post Polio Psychiatric Problems Respiratory Failure Quadriplegia / Tetraplegia Seizures Skin Problem ▇▇▇▇▇ Bifida Spinal Problems Stroke Ventilator Use ▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Date Patient Name Medical Record Number
Appears in 3 contracts
Sources: Patient Agreement for Outpatient Services, Patient Agreement for Outpatient Services, Patient Agreement for Outpatient Services