*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
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- Lisa Agatha Warner
- 5 years ago
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1 *542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only the areas related to your visit today. History of your current problem: How long has this problem been present? Since / / (or) for days months years What caused the problem to start? unknown reason accident ( motor vehicle motorcycle fall) other (please describe) Did the problem start at work? No Yes Will you file a worker s compensation claim? No Yes How do you describe your pain? aching burning sharp or stabbing numbness or tingling other How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months What makes the problem better or worse? Have you recently been seen in an emergency room for this problem? How long have you been seeking treatment for this problem? Treatments (non-surgical) I ve had for this problem have included: better worse No Yes Date / / or days months ago Hospital Treatment in ER: x-rays (describe results) weeks/months/years No treatment changing activity pain medicine physical therapy - general physical therapy - specific for hip or knee shots If you had a shot, what medicine? Other treatments: Assessment/ Original: Medical Record Page 1 of 5
2 Please list the doctors you have seen for your problem Treatment Specialist? City Describe surgery you ve had for your problem Doctor Specialist City Medicines you take for this problem Name of medicines Dose For how long? anti-inflammatory (to reduce swelling) narcotic pain reliever other X-rays and tests for this problem Results Date Where was test done? plain X-rays MRI CT scan bone scan other Past medical history Check all items that apply and describe if necessary. If no items apply, do not check off. Anesthesia problems: If yes, please describe None Heart: heart attack heart failure stroke Circulation: high blood pressure poor circulation Lungs: emphysema asthma lung disease pneumonia tuberculosis Assessment/ Original: Medical Record Page 2 of 5
3 Diabetes: Year diagnosed treated with (check all that apply): diet oral meds insulin Neuropathy (loss of feeling in hands or feet) Gland problems: thyroid adrenal pituitary Blood problems: bleeding disorder anemia high cholesterol/lipids Cancer (type ). Are you being treated for cancer? yes no Stomach: stomach ulcers hiatal hernia Kidney: kidney failure kidney stones Liver: hepatitis ( a b c ) cirrhosis Mental illness: depression seizures alcoholism AIDS Bone/joint: fractures osteoarthritis rheumatoid arthritis osteoporosis gout Blood clots: blood clot in leg blood clot in lung Descriptions/other: History of surgery (other than those stated above) No other past surgery Surgery Date Surgeon Family history (check all that apply) none apply heart trouble diabetes bleeding problems stroke high blood pressure arthritis gout seizures cancer kidney trouble spine problems mental illness alcoholism lung problems other. Assessment/ Original: Medical Record Page 3 of 5
4 Social history (check all that apply) Work Job working unemployed on leave retired disabled if you are on disability, what is the reason? Marital status married single live with a partner divorced widowed Children boys / girls Live with alone spouse partner children roommate other Tobacco use never cigarettes cigar pipe chew packs per day for years (total) Quit years ago Alcohol use never rare social often (more than twice a week) alcoholic recovering alcoholic Drug use never in past currently types of drugs Review. Do you currently have or have you had problems with: Check all items that apply and describe below if necessary. If no items on a line apply, do not check off. None fever chills weight loss eyes: reading glasses change of vision ears: hearing loss ear pain vertigo (dizzy) nose / mouth / throat: nosebleeds hoarseness bleeding gums tooth or gum trouble lungs: cough shortness of breath pneumonia asthma emphysema stomach: nausea vomiting stomach pain ulcers bowels: frequent diarrhea frequent constipation hemorrhoids urinary tract frequent peeing or burning when you pee trouble starting flow glands diabetes hyperactivity growth changes heart: chest pain palpitations abnormal heartbeat swollen ankles skin: rashes skin sores scars dermatitis brain: seizures frequent headaches memory loss blackouts psychological problems: depression hallucinations frequent anxiety trouble sleep neuropathy or loss of feeling in hands or feet blood: bleeding anemia swollen lymph nodes non-drug allergies: allergies to foods seasonal allergies other non-drug allergies reproductive system: irregular periods vaginal discharge frequent spotting Description/other: Assessment/ Original: Medical Record Page 4 of 5
5 Because of your joint problem(s) you plan to file: a lawsuit a workman s compensation claim neither a lawsuit or a workman s compensation claim Signature of person filling out form: Date: Time: Assessment: ******** Office use only ******** Orders: Follow-up / plan: Staff Signature: Date: Time: Assessment/ Original: Medical Record Page 5 of 5
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ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION Personal Mr. Ms. Mrs. Miss Dr. Other Last Name First Name MI Home Address City State Zip Mail Address City State Zip Is This a Nursing Home? Facility Name Telephone # Cell Phone
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?