새환자용의료설문 / New Patient Medical Questionnaire 날짜 / DATE: 환자성함 / Patient Name: 생년월일 / Date of Birth: 나이 / AGE: 차진료의 / Primary Care Physician: 다른의사 / Other Physicians: 어떤의사는이상담을요청했습니까? / What physician requested this consultation? 약국이름 / Pharmacy Name: 위치 ( 가장가까운교차로 ) / Location (nearest intersection): 주요호소증상 / CHIEF COMPLAINT 오늘어떤문제로여기오셨습니까? / What problem(s) are you here for today? 관상동맥위험요인 / CORONARY RISK FACTORS: ( 다음중하나라도있거나있었던적이있으면체크하시고그것이처음으로발견된년도를쓰시기바랍니다 ) / (please check if you have or have had any of the following and year it was first identified) 고혈압 ( 고혈압 ) 심장질환가족력 / Hypertension (high blood pressure) / Family History of heart disease 당뇨병 ( 그렇다면, 약복용또는인슐린주사 ) 폐쇄성수면무호흡증 / Diabetes (if yes, taking pills or insulin) / Obstructive Sleep Apnea 비정상적인 / 높은콜레스테롤 CPAP 기계 / Abnormal/High Cholesterol / CPAP Machine 말초동맥질환 ( 경동맥, 다리 ) 현재흡연자또는 이전흡연자 / Peripheral Artery Disease (carotid, legs) / Current smoker or Former Smoker 심혈관병력 / CARDIOVASCULAR HISTORY 해당하는모든곳에체크하시고, 처음으로진단된연도를쓰시기바랍니다. / Please check any for all that apply, and year of first diagnosis. 관상동맥질환 경동맥질환 / 협착증 / Coronary Artery Disease / Carotid Artery Disease/Stenosis 심장마비 폐색전증 ( 폐에혈액이응고되는증상 ) / Heart Attack / Pulmonary Embolism (blood clot in lung) 확대심장 동맥류 / Enlarged heart / Aneurysm 심장잡음 심박조절기 / Heart Murmur / Pacemaker 뇌졸중또는 TIA ( 약한뇌졸중 ) 제세동기 / Stroke or TIA (mini-stroke) / Defibrillator
심장판막증 부정맥 ( 비정상적인리듬 ) / Heart Valve disease / Arrhythmia (Abnormal Rhythm) 말초동맥질환 ( 다리동맥에막힘이있음 ) / Peripheral Arterial Disease (blockages in leg arteries) 심부전 ( 약한심장근육 ) / Congestive heart failure (weak heart muscle) 심부정맥혈전증 (DVT, 다리에혈액응고있음 ) / Deep Vein Thrombosis (DVT, blood clot in leg) 어떠한심장질환으로든입원한적있음 / Hospitalization for any heart reason 심장수술 / 진단테스트 / CARDIAC PROCEDURES/DIAGNOSTIC TESTING 해당하는모든곳에체크하시고수술연도를쓰시기바랍니다. / Check for all that apply and year of procedure. 심장도관삽입술 / Heart or Cardiac Catheterization 심장 / 다리또는기타혈관형성술 / 스텐트삽입 / Heart / Leg or other Angioplasty / Stent Placement 전기생리학또는절제시술 / Electrophysiology or Ablation Procedure
새환자용의료설문 / New Patient Medical Questionnaire 환자성함 / Patient Name: 생년월일 / DOB: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 현재복용하는약 / CURRENT MEDICATIONS / 보충제 / SUPPLEMENTS 가정에서복용하는모든약의목록을작성해주시기바랍니다. 모든처방약, 비처방약, 비타민, 한약및 보충제를포함시켜주십시오. / Please list ALL medications that you are taking at home. Include ALL prescription medications, nonprescription medications, vitamins, herbal remedies and supplements 약의이름 / Name of Medication 복용량 / / Dose / 복용횟수또는복용하는때 / How often or when taken 예 : 래식스 (lasix) 40 mg 하루에두번 / Example: lasix 40 mg twice a day ( 필요하면추가페이지를첨부하시기바랍니다 ) / (Please attach additional pages if necessary) 약에대한알레르기 / ALLERGIES / 과민증상 / INTOLERANCES TO MEDICATIONS 알레르기, 부작용또는과민증상이있는모든약, 음식, 대조염색약또는요오드등물질의목록을 작성하시고그반응을설명하시기바랍니다. / Please list any medications, foods, or materials such as contrast dye or iodine that you are allergic to, had an adverse reaction to or do not tolerate and describe the reaction. 의학적반응 ( 예, 두드러기, 부어오름, 숨가쁨, 발진, 등 ) / Medication Reaction (e.g. hives, swelling, shortness of breath, rash, etc.) 예 : 리피토 (lipitor)-> 두드러기, 근육통 / Example: lipitor -> hives, muscle aches 외과병력 / SURGICAL HISTORY / 수술 / OPERATIONS 귀하가받은기타모든외과수술의목록을작성하고그연도를기입하시기바랍니다. / Please list any other surgeries you have had and include the year. 수술 / Surgery 날짜 / Date 예 : 담낭제거 / Example: Gallbladder Removed 1988
새환자의료설문 / New Patient Medical Questionnaire 환자성함 / Patient Name: 생년월일 / DOB: 과거의병력 / PAST MEDICAL HISTORY 해당하는모든곳에체크하시고그것이처음으로발견된연도를기입하십시오. / Check for all that apply and indicate the year it was first identified 폐 / PULMONARY: 천식폐렴 / Asthma / Pneumonia 기종 / Emphysema / COPD / COPD 위장 / GASTROINTESTINAL: 위장출혈 궤양 / Gastrointestinal Bleeding / Ulcers 역류성식도염 ( 위식도역류 ) 간질환 / 간염 / Reflux (GERD) / Liver Disease / Hepatitis 신장 / 비뇨 / RENAL/GENITOURINARY 신장질환 / 크레아티닌상승전립선질환 / Kidney Disease / Elevated Creatinine / Prostate Disease 투석 / Dialysis 신경 / 심리적 / NEUROLOGICAL / PSYCHOLOGICAL: 두개내 ( 뇌내부 ) 출혈 발작장애 / Intracranial (in the brain) Bleeding / Seizure Disorder 치매 우울증 / Dementia / Depression 불안장애 파킨슨병 / Anxiety Disorder / Parkinson s 여성생식 / FEMALE REPRODUCTIVE: 해당되지않음 / Not Applicable 폐경 ( 몇세에?) 현재임신중 ( 임신주수 ) / Menopause (at what age?) / Currently Pregnant (number of weeks) 내분비 / ENDOCRINE: 갑상선질환 / Thyroid Disorder 기타 / OTHER: 암 ( 유형 ) HIV / Cancer (type) / HIV 응고장애 자가면역질환 ( 예. 낭창 ) / Clotting Disorder / Autoimmune Disorders (i.e. Lupus) 출혈장애 관절염 / Bleeding Disorder / Arthritis 빈혈 / Anemia
사회력 / SOCIAL HISTORY: 결혼상태 ( 해당하는곳에동그라미하세요 ) / Marital Status (circle): 미혼 / Single 결혼 / Married 이혼 / Divorced 별거 / Separated 사별 / Widowed 동거파트너 / Domestic Partner 자녀수 / Number of children: 누구와함께살고있습니까? / With whom do you live? 은퇴하셨습니까?: 예아니오현재또는이전직업 : / Are you retired: Yes No Current or Previous Occupation: 여가활동 / Leisure activities: ( 모든취미를기입하십시오 ) / (Include any hobbies) 운동 ( 해당하는곳에동그라미하세요 ) / Exercise (circle) 아니오 / No / 앉은자세에서 / Sedentary 가끔 / Occasional 정기적으로 / Regular 활동적인라이프스타일 / Active Lifestyle 육체적으로운동이불가능합니다 / Physically unable to exercise 운동의유형및길이 ( 몇분간, 주당횟수 )/ Type of exercise and how long (how many minutes and times per week):
새환자의료설문 / New Patient Medical Questionnaire 환자성함 / Patient Name: 생년월일 / DOB: 담배를피십니까? / Do you use tobacco? 예 / Yes 예전에핌 / Formerly 핀적없음 / Never 담배 / Cigarettes / 시가 / Cigars / 파이프 / Pipe 씹는담배 / / Chewing tobacco / 전자담배 ( 이중하나에동그라미하세요 ) / Electronic cigarette (Circle which one) 하루당 / per day 담배핀연수? / Years Smoked? 담배를끊은날짜는? / Quit Date? 알코올을섭취하십니까? / Do you use alcohol? 예 / Yes 예전에섭취함 / Formerly 섭취한적없음 / Never 맥주 / Beer 와인 / / Wine / 스피리츠 / Spirits ( 해당하는곳에동그라미하세요 ) / (Circle which one) 하루 / servings per day / 일주 / wk / 1 개월 / mo / 1 년 / yr 당주량 카페인을드십니까? / Do you use caffeine? 예 / Yes 예전에마셨음 / Formerly 마신적없음 / Never 카페인있는커피 / Caffeinated Coffee / 차 / Tea / 소다? / Soda? ( 해당하는곳에동그라미하세요 ) / (Circle which one) 하루 / cups per day / 일주 / wk / 1개월 / mo / 1년 / yr 당마신컵수 기본전환용약물을사용합니까? / Do you use recreational drugs? 예 / Yes 예전에사용함 / Formerly 사용한적없음 / Never 마리화나 / Marijuana / 코케인 / Cocaine / 메탐페타민 / Methamphetamine / 헤로인 / Heroin / 기타 / Other 끊은날짜는? / Date quit? 재활치료? / Rehab? 현재어떤특정다이어트를하는중입니까? / Currently on any particular diet? 어떤것입니까? / Which one?: 가족력 / FAMILY HISTORY: 만약귀하의아버지, 어머니, 형제 ( 들 ) 또는자매 ( 들 ) 이다음과같은진단을받았거나받았었다면그것에대해표시하고그진단을받은때그들의나이를표시해주시기바랍니다. / Please indicate if your Father, Mother, Brother(s) or Sister(s) have or have had the following diagnoses and their age when it was diagnosed. 심장마비, 뇌졸중, 혈관형성술 / Heart Attack, Stroke, Angioplasty / 스텐트, 심장수술, 울혈성심부전, 혈전, 동맥류, 또는비정상적인심장리듬 / Stents, Heart Surgery, Congestive Heart Failure, Blood Clots, Aneurysm, or Abnormal Heart Rhythm 현재나이 / Current Age 진단명 / Diagnosis 사망한나이 ( 해당되는경우, 사망원인도작성해주십시오 ) / Age of Death (if applicable and cause of death) ( 진단시나이 ) / (age of diagnosis) 아버지 / Father 어머니 / Mother 형제 ( 들 ) / Brother(s) 자매 ( 들 ) / Sister(s) 기타 / Other
입양되었거나가족력을알수없으면여기에체크해주십시오 / Check here if Adopted / Unknown family history
새환자의료설문 / New Patient Medical Questionnaire 환자 / Patient 성함 / Name: 생년월일 / DOB: 시스템검토 / REVIEW OF SYSTEMS 날짜 / Date: 만약귀하가다음증상중하나를가지고있다면체크해주시기바랍니다. / Please check if you have any of the following symptoms: 체질 / CONSTITUTION 눈 / EYES 위장 / GASTROINTESTIONAL 내분비 / 혈액 / 알레르기 / ENDO/HEME/ALL 열 / Fever 오한 / Chills 체중감소 / Weight loss 피로 / Fatigue 땀흘림 / 발한 / Sweating/Perspiration 허약함 / Weakness 피부 / SKIN 발진 / Rash 가려움증 / Itching HENT / HENT 두통 / Headaches 청력상실 / Hearing loss 귀울림 / Ringing in the ears 귀통증 / Ear pain 귀분비물 / Ear discharge 코피 / Nosebleeds 막힘 / Congestion 인후염 / Sore throat 흐린시야 / Blurred vision 복시 / Double vision 빛에민감함 / Sensitive to light 눈의통증 / Eye pain 눈분비물 / Eye discharge 충혈된눈 / Eye redness 심장혈관 / CARDIOVASCULAR 가슴통증 / Chest pain 심계항진 / 가슴두근거림 / Palpitations/flutters 숨가쁨누울때 / Shortness of breath when lying down 걷는동안다리통증 / Leg pain while walking 다리붓기 / Leg swelling 자다깸숨참 / Waking from sleep short of breath 호흡기 / RESPIRATORY 기침 / Cough 피를토함 / Coughing up blood 가래생김 / Sputum production 속쓰림 / Heartburn 구역질 / Nausea 구토 / Vomiting 복부통증 / Abdominal pain 설사 / Diarrhea 변비 / Constipation 대변에혈액검출 / Blood in stool 검은변 / Black stool 비뇨 / GENITOURINARY 고통스런배뇨 / Painful urination 긴급 / Urgency 소변횟수 / Urinary frequency 소변에서혈액검출 / Blood in urine 옆구리통증 / Flank pain 근골격 / MUSCULOSKELETAL 근육통 / Muscle pain 목통증 / Neck pain 허리통증 / Back pain 관절통 / Joint pain 멍이잘든다 / Easy bruising 알레르기 / Allergies 과도한갈증 / Excessive thirst 신경 / NEUROLOGICAL 현기증 / Dizziness 따끔거림 / Tingling 떨림 / Tremor 감각변화 / Sensory change 음성변경 / Speech change 부분허약 / Focal weakness 발작 / Seizures 의식상실 / Loss of consciousness 정신 / PSYCHIATRIC 우울증 / Depression 자살충동 / Suicidal ideas 약물남용 / Substance abuse 환각 / Hallucinations 긴장 / 불안 / Nervous/Anxious 불면증 / Insomnia 숨참 / Short of breath 넘어짐 / Falls 기억손실 / Memory loss 천명 / Wheezing