Vernon A. Rosario, MD, PhD ADULT MEDICAL SCREENING Patient Information Chief Complaint Personal Medical History
Do you receive regular medical care from a physician or clinic?
If yes, please provide the following information: Name of physician or clinic: Address: CURRENT MEDICATIONS: MEDICATION ALLERGIES: Penicillin
Have you ever had any of the following: Birth Defects
If yes, please explain (continue on the back): Have you had any other disease?
What is your current weight (estimate if you do not know exactly)? What is the most you have ever weighed?
Can you explain any recent weight loss or weight gain?
Have you ever had surgery , or been advised to have surgery?
Do you have Hay Fever or food allergies? Have you recently had any of the following tests?
Have you ever used the following and how much do you currently consume? Coffee (cups/day)
Have you ever used any of the following? (Circle the ones used) Celexa
Please detail periods of use, dosages, reasons for use, and reason for discontinuation of the above (continue on reverse).
Personal Psychiatric History
Have you ever received any previous psychiatric or psychological evaluation or treatment?
YES If yes, please describe when, how, what happened?
Please describe any family history of medical illnesses (such as cancer, hypertension, diabetes, neurological disorders): Please describe any family history of mental health problems, such as depression, manic-depression (bipolar), anxiety, schizophrenia, suicides, substance use, learning disorders, autism:
Review of Your Current Health
Do you have any of the following? (Please circle) Unusual excessive thirst
Shortness of breath at night or with exercise
Problems with memory, thinking, or concentration
Blood in stool Change in appetite or eating habits Please describe on the reverse any of the positive answers above. for women only: Date your last menstrual period began:
Have you had a Pap smear within the last year?
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
NOTICE OF PRIVACY PRACTICES Acknowledgement of Receipt Vernon A. Rosario II, MD, PhD 10850 Wilshire Blvd. Suite 1210 Los Angeles, CA 90024 310-470-9775 I hereby acknowledge that I reviewed and downloaded a copy of this medical practice's Notice of Privacy Practices on-line at: http://vrosario.bol.ucla.edu/forms/HIPAA_PatientNotice.pdf I further acknowledge that a copy of the most current notice will be available on-line A print copy of the current Notice of Privacy Practices will be available at each appointment upon request. Signed: ______________________________Date: __________________________________ Print Name: __________________________Telephone: _____________________________ If not signed by the patient, please indicate relationship: Parent or guardian of minor patient Guardian or conservator of an incompetent patient Name and Address of Patient: ____________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
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