WPC UFaJ\ˆ! *$aC&!w% QB-VpZ@Uuv^eݙejsHQNȆƦӚ韓ûHyA)2  QLLxiN\-LVÇN#ۜhK͢ҋBY9H ĭr45ͨ>e&%َ,Gkb\j'/x#B*ڵ۸1i%;;/-vC%V0&gfXX.2%WXQȘHFhܜGk_"+ӶNg^E 8 !Y[&K#p5ιIJ=-Yq uw&R&88NƖM[P!frB\kg<U"ֆJ 'ņ V6 c?ϰ+56ZÔ2Zނ#U >z 0FUF0 0 0  UBS 0< B D/ D+ "H UPj  0 # UNA %M(N^ w4 m\  `&Times New Roman' JEFFREY DICKERSON Shepard0Shepard .   6 4Heading 1XXXE*jp`GaramondE XXYZ%   G=XX` hp x (#%GS\  `&Times New RomanS *jp`Garamond6 4Heading 2XXXE*jp`GaramondE 8 >4 ` hp x (#%>    D:XX` hp x (#%DS\  `&Times New RomanS 6 4Heading 3W*jp`*Bookman Old StyleW 2(X X<hp x (#%2   >4XX` hp x (#%>S\  `&Times New RomanS *jp`*Bookman Old Style<:Default Para d )1dxd'dxd     \  `8Times New RomanCondensed#|x(z$XX..      8XX88HP OfficeJet R Series0(,,,,0(0(9 Z6Times New Roman RegularXE'y*L B(~R1.WPDU z!XX..      8XX88  _         <(X X*hp x (#%X<U}89U} JEFFREYDICKERSON  Pulmonologist  MedicalSpecialistsofHelena   2525BroadwaySuite200  Helena,MT.59601  406-457-4343  fax#406-4574344  $   6XXVx (#%XX*hX%6Yourappointmentisscheduledfor____________________________  0 at_______________  6   T4XX` hp x (#%XXVxX%TYouhavebeenscheduledforaPulmonologyconsultation.Pleasecompletethismedical B  historyquestionnaireBEFOREyourscheduledappointmentandbringitwithyouwhenyoucome. H  Ifeelthisinformationisessentialtoathoroughevaluation,anditscompletionwillallowusmore N  timeforadetaileddiscussionofyourmainproblem.Ifyoumisplacethisquestionnairepleasecall T ourofficeforanothercopy.Itmaybenecessarytorescheduleyourappointmentifyoudonothave Z thequestionnairecompletedwhenyouarrive. `   ItisnecessarythatyouhaveaprimaryphysiciantowhomIwillsendyourconsultation l reportandwhowillprovidelong-termfollowupcare.Iamavailableforcareduringclinichours r andifyouhavequestionsorareexperiencingsomeproblemsyouwouldliketodiscuss,pleasecall. x Afterhours,holidays,andweekendsyouwillneedtocontactyourprimaryphysician. ~  Q4XX` hp x (#%XXX%QMyofficeislocatedonthesecondfloorofthenewMariaDeanMedicalBuildinginSuite200east  ofSt.Peter'sHospital.IrecommendthatyouusethenorthentrancefacingBroadway,andtakethe  elevatortosecondfloor.   ! XX%XXX%!X>OX9  MARIADEANMEDICALSPECIALISTS e 2525Broadway,Suite200 F Helena,Montana59601 ' Fax:(406)457-4344  Ph.:(406)457-434 3 e     $XX %XX%$ &Dr.Anderson&Dr.Dietz@..&Dr.Dickerson  '   X>OXXX>OX>OXXX>O*XXYZ%XX %*      &     & Dr.Eden@.. & DrSnyder +   Ԍ m   Ќ*XX %XXYZ%*X>OXXX>OX>OXXX>O    $ XX%XX %$'m  Name:_______________________________________________________________________________ /  Whoreferredyou?______________________________________________________________________ m  Whoisyourfamilydoctor?_______________________________________________________________ /  Pleasebrieflydescribewhy XX>OyouX>OX arebeingseentoday?9XX>O_____________________________________  _________________________________________________________________________X>OX9  $XXYZ%XX%$K (XK$ XX%XXYZ%$Pleasebrieflylistanyconditionsorchronicillnessesyouhave(suchashighbloodpressure,diabetes,depression,  glaucoma,prostateproblems,sleepdisturbances,thyroiddisease,lungdisease,,highcholesterol,mentalillness, b etc.,...):______________________________________________________________________________ C ____________________________________________________________________________________ $ ____________________________________________________________________________________  ____________________________________________________________________________________ b K (X=KH4XX` hp x (#%XX%HPleaselistanymajorillnessorsurgeriesthatyouhavehad?______________________________________  ____________________________________________________________________________________  ____________________________________________________________________________________ d ____________________________________________________________________________________ E ____________________________________________________________________________________ & Pleaselistallofyourcurrentmedicationsanddosage.Thisshouldincludeallprescription,andover-the-counter  d! medicationsincludingvitamins.andherbalsupplements:________________________________________ !E" ____________________________________________________________________________________ "&# ____________________________________________________________________________________ # $ ____________________________________________________________________________________ l$ % ____________________________________________________________________________________ M%!& $ XX%XXX%$Areyoutakingbloodthinnermedicationssuchas_Coumadin_ԀorHeparin?  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Q7XX` hp x (#%X%Q < hx (#%XXX%<Cancer-Typeofcancer:_____________ XXXX>O_  X>OXX XWhichfamilymember?________________________ M    <X h%hxX%<Headaches X Depression h LiverDisease  Diabetes B  Stroke X Tremors h HeartDisease  RheumatoidArthritis #  Alcohol/DrugAddiction h EpilepsyorSeizures  HighBloodPressure   BrainHemorrhage(oraneurysm) h DisordersofMusclesorNerves a   6XXX h%X h%6 @Q1 hp x (#%XXX h%Q PersonalHistory #  @Q1XX hp x (#% X%QXX>O <X a$%XX X%<9&kÀi9ԀX>OXikÀSingle X 9XX>O&X>OX9ԀMarried  9XX>O&X>OX9ԀDivorced  9XX>O&X>OX9Widowed  9XX>O&X>OX9Ԁ#ofMarriages____ C  BXXX a$%X a$BZ4XX` hp x (#%XXX a$ZLevelofEducation:_________________________________________________________________________ l 9XX>O&X>OX9ԀWorkingor9XX>O&X>OX9ԀRetiredMostrecentoccupations: . _____________________________________________ 4  0- #%XXX%-AreyoupresentlyreceivingWorkersCompensationorSocialSecuritybenefitsbecauseofadisability? r   9XX>O&X>OX9ԀYes 9XX>O&X>OX9No S  06XX #% #6- XX#%XX #-Ifyourproblemisrelatedtoaninjuryoraccident,areyourepresentedbyanattorney?9XX>O&X>OX9ԀYes9XX>O&X>OX9ԀNo : K4XX` hp x (#%XX#%KIfYes;listthenameoftheattorney:____________________________________________________________ ! 0XX k #(#%XXX%0Doyousmoke?9XX>O&X>OX9ԀYes 9XX>O&X>OX9No  Howmanypacksperday?_________ k Howmanyyears?________ g   E"X X 4 x (#%XX k #(#%EDoyouchewtobacco? 9XX>O&X>OX9ԀYes  9XX>O&X>OX9ԀNo 4 Howmuch?____________________________ N"" Z4XX` hp x (#%XX 4 X%ZDoyoudrinkalcohol?9XX>O&X>OX9ԀYes9XX>O&X>OX9ԀNo  IfYes,onaveragehowmanydrinksperweekdoyouhave?___________ 5$ $ 3XX} x (#%XXX%3Doyouusemoodalteringoraddictivedrugs?9XX>O&X>OX9ԀYes9XX>O&X>OX9ԀNo &"& ?"X Xp x (#%XX}X%?IfNo,haveyoudonesointhepast?9XX>O&X>OX9ԀYes9XX>O&X>OX9ԀNo ($( Q4XX` hp x (#%XXX%QHaveyourecentlybeenunderanysignificantorunusualfamily,marital,legal,job-relatedorotherstress? )f&* Pleasedescribe:___________________________________________________________________________ *G'+ ________________________________________________________________________________________ +((, ________________________________________________________________________________________ , )- XX>O8  O.*/          9"X X p x (#%XXX%98:HELENAMEDICALSPECIALISTS  MARIADEANBUILDING 4 2525BROADWAY ` HELENA,MT59601    6XX> (#%XX pX%6CHARLESB.ANDERSON,M.D. > KENNETHV.EDEN,M.D. p ADULTNEUROLOGY > GASTROENTEROLOGY   MARKDIETZ,M.D. > JEFFREYDICKERSON,M.D.   ADULTNEUROLOGY > PULMONOLOGY  0  ARTHURSNYDER,M.D.    RHEUMATOLOGY  @    B" _p x (#%XX> (#%BBILLINGINFORMATION $    B"X X_p x (#%_pX%B:::: H(X X<hp x (#%XX_pX%H    &  9  IFYOUARECOVEREDBYMEDICAID99  9Ԍ   Ќ3XX_pX%XX<hX%3::::  [T4XX` hp x (#%XX_pX%TYOUMUSTPRESENTYOURCURRENTCARDATEACHVISIT.YOURPHYSICIANHASTHERIGHTTOREFUSE 4  SERVICESIFYOUDONOTHAVEYOURCARD.'9 `   [:::: E(X X<hp x (#%XXX%E    ?"X Xp x (#%XX<hX%?& p ;  IFYOUARECOVEREDBYWORKER'SCOMPENSATION;<  <Ԍ D  Ќ0XXX%XXX%0::::  [YOUMUSTBRINGYOURCLAIMNUMBER,DATEOFINJURY,ANDTHENAMEOFTHEWORKER'S p COMPENSATIONAGENCY.THISINFORMATIONCANBEOBTAINEDTHROUGHYOUREMPLOYERORYOURWORKER'S   COMPENSATIONAGENT.ASTHEPATIENTRECEIVINGSERVICES,YOUAREULTIMATELYRESPONSIBLEFOR T PAYMENTSHOULDWORKER'SCOMPENSATIONCOVERAGEBEDENIED.'pD<   [:::: E(X X<hp x (#%XXX%E    3XX0x (#%XX<hX%3&  ?  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