The Mount Sinai Medical Center

THE PROGRAM FOR DIAGNOSTIC

AND PREVENTIVE MEDICINE

Date:________________

Dear_____________________________:

Welcome to The Mount Sinai Program for Diagnostic and Preventive Medicine.
You are scheduled to meet with Dr. _______________________ on (day)________________(date) _____________
at (time) _________________. If for any reason you are unable to keep this appointment, please let us know as soon as
possible. Our office is located on Fifth Avenue at 100th street, entry level.
Please return the following items to us in advance of your visit:
(1) medical records you think may be relevant, including reports of any testing carried out within the past year
(2) the attached questionnaire, completed as best you can
(3) a list of particular questions you would like the doctor to answer.

Sincerely,
The Program for
Diagnostic and Preventive Medicine

FIFTH AVENUE AT 100TH STREET  NEW YORK, NY 10029  TELEPHONE (212) 241-8000  FACSIMILE (212) 831-2195

PROGRAM FOR DIAGNOSTIC AND PREVENTIVE MEDICINE

PATIENT INFORMATION

Physician: ___________________________________________________

Date of Visit: ____________________________

Please complete the following:

Name of patient (if indicated incorrectly): _____________________________________________________________________________
Address: ______________________________________________________________________________________________________
Telephone: Day (
Email address:

) _________________________________________
____________________________________________

Evening (
Fax: (

) ___________________________

) _______________________________

Social Security Number: _____________________________________________________________________________________

Date of Birth: _________________________________________________________________________________________________
Birthplace: ___________________________________________________________________________________________________
Mount Sinai Unit Number (if available): ______________________________________________________________________
Are you employed?

Yes

No

Retired?

Yes

No

Occupation: __________________________________________________________________________________________________
Who should be contacted regarding appointments and other matters?
Self:

Other person: ____________________________________________________________________________________

Marital status:

Married

Single

Divorced

Widowed

Have you signed an Advanced Healthcare Directive? __________________________________________________________

Who can be contacted in case of an emergency? ______________________________________________________________
Name: ________________________________________________________________________________________________________
Address: ______________________________________________________________________________________________________
Telephone: Day (

) _________________________________________

Evening (

) ___________________________

Relationship to you: __________________________________________________________________________________________

PROGRAM FOR DIAGNOSTIC AND PREVENTIVE MEDICINE

Please list the names and telephone numbers of others involved in your care:
Physician
Specialty
Address
Telephone

Are you currently under a physicians care for any ailment or injury?

Yes

No

Receive Report

Why have you scheduled an appointment with the doctor at this time, and what are your expectations?
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

Are you taking any prescription medications?

Please have these available at your visit.
Name of Medication

Yes

Dosage

Frequency

Are you taking any OTC/non-prescription medications?

Name of Medication

Dosage

(If no skip to next)

Any Side Effects?

Yes
Frequency

No

No

Any Side Effects?

(If no skip to next)

PROGRAM FOR DIAGNOSTIC AND PREVENTIVE MEDICINE

Are you taking any vitamins, homeopathics, herbal medicines or supplements?

(If no skip to next)
Name of Supplement

Freqency

Have you ever had a bad reaction to any medication or supplement?

Name of Medication / Supplement

Dosage

Yes

No

Any Side Effects?

Yes

No

 Not Sure 

Yes

No

Reaction

Are you allergic to any other substances?

(If no skip to next section)
Name of Medication / Supplement
Reaction

Not Sure

CONSTITUTIONAL/SYSTEMIC:
What is your current weight? ___________________________________________________________________lbs
What is your height? ___________________________________________________________________________lbs
What is the least you have weighed in the past 5 years? _______________________________________lbs
What is the most you have weighed in the past 5 years? _______________________________________lbs
Have you had recent unexplained weight gain?
Yes
No
Have you had recent unexplained weight loss?
Yes
No
How many hours do you sleep on average at night? __________________________________________hours
Are you frequently tired?
Yes
No
Are you having trouble sleeping?
Yes
No
If yes, please explain: ________________________________________________________________________
Have you had recent fevers, night sweats or chills?
Yes
No
Do you regularly use a seatbelt in automobiles?
Yes
No



















PROGRAM FOR DIAGNOSTIC AND PREVENTIVE MEDICINE

MEDICAL HISTORY
Please do not leave urgent information on this form.
If you need medical advice or are not sure what type of care you need, please call 1-800-MD-SINAI

Have you had any major illnesses or surgeries?

Yes

No

______________________________________________________________________________________________________________
Condition

Year

Where Treated

______________________________________________________________________________________________________________
Condition

Year

Where Treated

______________________________________________________________________________________________________________
Condition

Year

Where Treated

______________________________________________________________________________________________________________
Condition

Year

Where Treated

LIFESTYLE







a.) Have you ever smoked cigarettes?

Yes
No
How many years have you smoked? ______________________________________________________________________
How many packs per day? __________________________________________________________________________________
If you have quit, what year did you quit? ______________________________________________________________
Have you used tobacco in other forms (pipe, cigars, chew)?
Yes
No
Are you exposed to second-hand smoke?
Yes
No
b.) Do you drink alcoholic beverages?
Yes
No
How many drinks per day? __________________________________________________________________________________
Do you have or do others express concerns about your drinking? ______________________________
______________________________________________________________________________________________________________________
Do you drink coffee or tea?
What are your hobbies?
Do you have any pets or animals?
Have you lived outside the United States?
Have you or your family recently experienced any life
changes or unusual psychological stress?

Yes
Yes
Yes
Yes






No
No
No
No






Yes

No

DIET AND NUTRITION

a.) Please characterize your current diet, describing your typical breakfast, lunch and dinner:
______________________________________________________________________________________________________________
b.) Do you have intolerance of any particular foods (lactose, gluten, etc.)?
______________________________________________________________________________________________________________
5

PROGRAM FOR DIAGNOSTIC AND PREVENTIVE MEDICINE

EXCERCISE
a.) Do you exercise regularly?

Yes

No

b.) What type of exercise and how often?

______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
c.) Do you know of any health reason that should limited you from participating in physical activity?
Yes
No
Not Sure

Explain: ____________________________________________________________________________________________________
______________________________________________________________________________________________________________

FAMILY MEDICAL HISTORY

Living

Deceased

Age

Mother
Father
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Sisters, Brothers (please specify):

Aunts, Uncles (please specify):

Children (please specify):

Major Illnesses / Cause of Death

PROGRAM FOR DIAGNOSTIC AND PREVENTIVE MEDICINE

Have you had the following immunizations?






Pneumonia Vaccine
Tuberculin (TB) skin test
Diptheria/Tetanus
Hepatitis A (2 shot series)

Year:
Year:
Year:
Year:

____________________
____________________
____________________
____________________






Influeza (flu)
BCG (to prevent TB)
Measles/Mumps/Rubella
Hepatitis B (3 shot series)

Year:__________________________
Year:__________________________
Year:__________________________
Year:__________________________

Have you traveled recently or plan to travel in the immmediate future? ___________________________________________

Have you ever had or tested positive for:







Chicken Pox
Tuberculosis
HIV
Hepatitis:
Venereal (sexually transmitted) disease:

Type: ______________________________________
Specify: __________________________________

Other tests:
Date

Result

Chest X-Ray:
Cholesterol Level:
Triglyceride Level:
Other Lipid Data:
Colonoscopy:

Mammogram:
Pap Test:
Bone Density Test:

PROGRAM FOR DIAGNOSTIC AND PREVENTIVE MEDICINE

SYMPTOM REVIEW
A

ENDOCRINE/GLANDULAR
Do you suffer from:
Feeling hot or cold all the time
Thyroid problems or goiter
Diabetes
Excessive thirst
Hyperthyroidism
Hyperparathyroidism
Testosterone deficiency
Cushings syndrome
Treatment with: steroids (prednisone etc)?
Intestinal disease, malabsorption
Gauchers disease

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes













No
No
No
No
No
No
No
No
No
No
No













Not
Not
Not
Not
Not
Not
Not
Not
Not
Not
Not

Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure













Yes
Yes
Yes





No
No
No





Not Sure
Not Sure
Not Sure





Yes
Yes




No
No




Not Sure
Not Sure




Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes















No
No
No
No
No
No
No
No
No
No
No
No
No















Not
Not
Not
Not
Not
Not
Not
Not
Not
Not
Not
Not
Not















DERMATOLOGIC/SKIN
Do you suffer with:
Skin trouble or rash
Flushing
Change in hair or nails

HEENT
Do you suffer with:
Headache or migraine
Eye or vision problem
Eyeglasses or contact lenses?
If so, when was your most recent change in lens prescription?
Have you had a LASIK or other corrective eye surgery?
Have you ever had any other surgeries of your eyes?
Have you had cataracts or surgery to correct cataracts?
Have you had glaucoma?
Nose congestion or sinus trouble
Ear or hearing problem
Dental (tooth) problems
Dental plate, bridgework, or false teeth
Gingival (gum) problems or bleeding
Temporomandibular joint (TMJ) problems
Sore throat
Postnasal drip or secretions
Swollen lymph nodes
8

Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure

PROGRAM FOR DIAGNOSTIC AND PREVENTIVE MEDICINE

BREASTS
Do you have:
Breast cancer or a lump
Pain, tenderness or discharge

No
No




Not Sure
Not Sure




Yes
Yes
Yes
Yes
Yes







No
No
No
No
No







Not
Not
Not
Not
Not

Sure
Sure
Sure
Sure
Sure







Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes













No
No
No
No
No
No
No
No
No
No
No













Not
Not
Not
Not
Not
Not
Not
Not
Not
Not
Not

Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure













Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
















No
No
No
No
No
No
No
No
No
No
No
No
No
No
















Not
Not
Not
Not
Not
Not
Not
Not
Not
Not
Not
Not
Not
Not

Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
















CARDIOVASCULAR
Do you have:
Chest pain or tightness
Palpitations (skipped beats)
Swollen legs or feet
Hypertension (high blood pressure)
Hyperlipidemia (cholesterol, etc.)
Heart attack, angina
Heart murmur
Rheumatic fever
Claudication or leg pain on walking
Blood clots or phlebitis
Varicose veins




RESPIRATORY/LUNGS
Do you:
Have a cough
Have wheezing or shortness of breath
Snore
Have tuberculosis or pneumonia
Blood in sputum

Yes
Yes

ABDOMINAL/DIGESTIVE
Do you have:
Abdominal pain
Nausea or vomiting
Bloating, gas or indigestion
Heartburn
Ulcer
Difficulty swallowing
Jaundice
Liver disease
Gallbladder problems
Pancreatitis
Change in bowel habits
Black or bloody stool
Colon Cancer or Colon Polyps
Hemorrhoids
9

PROGRAM FOR DIAGNOSTIC AND PREVENTIVE MEDICINE

GENITAL/URINARY
Do you have:
Urinary problems (pain or frequency)
Blood in urine
Kidney stones
Urinary infections
Sexual dysfunction
Do you use a contraceptive?

Yes
Yes
Yes
Yes
Yes
Yes








No
No
No
No
No
No








Not
Not
Not
Not
Not
Not

Sure
Sure
Sure
Sure
Sure
Sure








Yes
Yes
Yes
Yes
Yes
Yes








No
No
No
No
No
No








Not
Not
Not
Not
Not
Not

Sure
Sure
Sure
Sure
Sure
Sure








Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes











No
No
No
No
No
No
No
No
No











Not
Not
Not
Not
Not
Not
Not
Not
Not

Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure
Sure











Yes
Yes
Yes
Yes
Yes







No
No
No
No
No







Not
Not
Not
Not
Not

Sure
Sure
Sure
Sure
Sure







MUSKULOSKELETAL
Do you have:
Joint or muscle pains or stiffness that limit mobility
Joint swelling, redness or deformity
Back pain
Fracture
Implanted plates, pins or screws
Osteoporosis

NEUROLOGICAL
Have you had or do you have:
Numbness or muscle weakness
Temporary loss of vision, speech or strength
Loss of consciousness (black-out spells)
Dizziness of lightheadedness
Impaired memory or confusion
Difficulty concentrating
A stroke
Panic attacks
Epilepsy or seizures

FOR MEN
Do you have:
Prostate problems?
Pain or lump in scrotum or testicles
Impaired libido (sex drive)
Difficulty with ejaculation
Discharge from penis

Other tests:
Date

Result

Prostate exam:
PSA level:
10

PROGRAM FOR DIAGNOSTIC AND PREVENTIVE MEDICINE

L

FOR WOMEN




Could you be pregnant?




Yes
No
Not Sure
Are you still having menstrual periods?
Yes
No
Not Sure
At what age did your menstrual periods begin? __________________________________________
Number of pregnancies __________________________________________________________________
Number of live births ____________________________________________________________________
Miscarriages______________________________________________________________________________




If you no longer have periods:

At what age did they stop? ______________________________________________________________
Do you experience hot flashes?
Yes
No
Not Sure
Do you experience vaginal dryness?
Yes
No
Not Sure
Have you had any bleeding since menopause?
Yes
No
Not Sure













If you still have menstrual periods:

How often do they occur? ________________________________________________________________
How many days do your periods last? ____________________________________________________
When did your last period begin? ________________________________________________________
Do you have severe cramps?
Yes
No
Do you have PMS/moodiness?
Yes
No
Do you spot/bleed between menstrual periods?
Yes
No
Do you have any vagina discharge
Yes
No
Have you ever taken birth control pills?
Yes
No
Have you ever had an abnormal PAP smear?
Yes
No
Do you perform breast self-examination?
Yes
No









Other tests:
Date

Result

Mammogram
Pap test:
Bone density test:

Are you taking medication forOsteoporosis?

Date Began

Estrogen
Fosamax
Evista
Miacalcin
Actonel
Calcium
Vitamin D
11

Result









Not
Not
Not
Not
Not
Not
Not

Sure
Sure
Sure
Sure
Sure
Sure
Sure









PROGRAM FOR DIAGNOSTIC AND PREVENTIVE MEDICINE

HAVE WE COVERED EVERYTHING?

Please enter any other information about your health that you would like the physician to know or address:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

12