Georgia Kidney Associates

Edward D. Himot, MD., Indira Chervu, M.D., F.A.C.P., Robert D. Jansen, M.D., Akin O. Ogundipe, M.D., F.A.C.P.,
Vijay Nath, M.D., Sandeep Jaglan, M.D., Amish Patel, M.D., Kimone James, M.D., Samuel A. Johnson, M.D.

Patient Information
First Name:
 
Last Name:

Date of Birth: (MM/DD/YYYY):
Referred By: Height:
Why were you referred?
Family History

  Have any of your relatives had any of the following diseases? If so, please indicate which relative(s) was (were) affected:

Disease Self Family Member
Arthritis Yes
No
Yes
No
Bleeding Problems Yes
No
Yes
No
Cancer Yes
No
Yes
No
Deafness Yes
No
Yes
No
Diabetes Yes
No
Yes
No
Heart Attack Yes
No
Yes
No
High Blood Pressure Yes
No
Yes
No
Inherited Disease Yes
No
Yes
No
Kidney Failure Yes
No
Yes
No
Lupus or Similar Disease Yes
No
Yes
No
Other Heart Disease Yes
No
Yes
No
Stroke Yes
No
Yes
No

Father: Living Yes
No
Health Status:
Cause of Death:

Mother: Living Yes
No
Health Status:
Cause of Death:

Brothers: Number Living:
Number Deceased:

Sisters: Number Living:
Number Deceased:

Children: Daughters
Sons
Social History
Cigarette Use: Yes
No
If yes, how much per day?
Alcohol Use: Yes
No
If yes, how often?
Recreational Drug Use: Yes
No
Current Work Status:
Marital Status:
Highest Education Level Attained:
Pharmacy:
Pharmacy Name:
Address:
Phone Number:
Medications:
Name of Medication: Dosage: Frequency:
Allergies - Reaction:
Allergies: Reaction:
Past Medical History:

 Surgeries and/or Hospitalizations

Procedure: Date: Yes/No:
Appendectomy Yes
No
Gallbladder Removed Yes
No
Heart Surgery Yes
No
Hysterectomy Yes
No
Transfusions: Yes
No
Others:
Review of Systems:

Please answer yes or no to each question and provide an explanation of any affirmative answer.

General: Yes/No: Explanation:
Anemia Yes
No
Bleeding Problem Yes
No
Change in appetite Yes
No
Change in weight Yes
No
History of Cancer Yes
No
Other Yes
No
Skin: Yes/No: Explanation:
Bruising Yes
No
Dryness Yes
No
Hair Loss/Gain Yes
No
Hives Yes
No
Itching Yes
No
Nail Problems Yes
No
Skin Cancer Yes
No
Skin Color Change Yes
No
Skin Rash Yes
No
Ulcer Yes
No
Other Yes
No
ENT: Yes/No: Explanation:
Changing Vision Yes
No
Deafness Yes
No
Glasses Yes
No
Sinus Problems Yes
No
Swallowing Problem Yes
No
Other Yes
No
Pulmonary: Yes/No: Explanation:
Asthma Yes
No
Chronic Bronchitis Yes
No
Chronic Cough Yes
No
Cough up Blood Yes
No
Cigarette Use Yes
No
Emphysema Yes
No
Pneumonia Yes
No
Shortness of Breath Yes
No
Other Yes
No
Cardiovascular: Yes/No: Explanation:
Abnormal EKG Yes
No
Blood Clots Yes
No
Cardia Catheter Yes
No
Chest Discomfort Yes
No
Chest Pain Yes
No
Fainting Yes
No
Heart Attack Yes
No
Heart Failure Yes
No
High Blood Pressure Yes
No
Irregular Pulse Yes
No
Palpations Yes
No
Rheumatic Fever Yes
No
Shortness of Breath Yes
No
Swelling Yes
No
Other Yes
No
Gastrointestinal: Yes/No: Explanation:
Blood in Stools Yes
No
Cancer Yes
No
Chronic Diarrhea Yes
No
Constipation Yes
No
Hepatitis Yes
No
Jaundice Yes
No
Ulcers Yes
No
Other Yes
No
Renal and GU: Yes/No: Explanation:
Bladder Infections Yes
No
Bladder Surgery Yes
No
Blood in Urine Yes
No
Bright's Disease Yes
No
Kidney Infections Yes
No
Kidney Failure Yes
No
Kidney Stones Yes
No
Prostate Disease Yes
No
Protein in Urine Yes
No
Voiding Difficulty Yes
No
Other Yes
No
Musculoskeletal: Yes/No: Explanation:
Broken Bones Yes
No
Deformed Joints Yes
No
Joint Pain Yes
No
Joint Swelling/Heat Yes
No
Other Yes
No
Neurologic: Yes/No: Explanation:
Change in Vision Yes
No
Dizziness Yes
No
Fainting Yes
No
Headaches Yes
No
Psychiatric Problem Yes
No
Seizures Yes
No
Stroke Yes
No
Tremor/Shakes Yes
No
Trouble Walking Yes
No
Other Yes
No
Skin Rash Yes
No
Skin Cancer Yes
No
Hair Loss/Gain Yes
No
Nail Problems Yes
No
Endocrine: Yes/No: Explanation:
Cortisone Use Yes
No
Diabetes Yes
No
NSAID Use Yes
No
Thyroid Disease Yes
No
Other Yes
No
For Women Only: Yes/No: Explanation:
Abnormal Bleeding Yes
No
Breast Cancer Yes
No
Breast Masses Yes
No
Breast Surgery Yes
No
Change in Periods Yes
No
Menopause Yes
No
Miscarriages Yes
No
Problem Pregnancies Yes
No
Toxemia Yes
No

Any further information which you believe is important may be provided in the space below.