Eastern Shore MediCann Clinic, LLC
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1 Eastern Shore MediCann Clinic, LLC New Patient Medical History and Intake Form Medical Marijuana Certification Name Date of Birth Social Security Number Gender: Male Female Address: Street: City: State Zip Code Home Phone: Cell Phone: Mother s Maiden Name: Emergency Contact Name: Phone: Primary Care Physician: Address: Street: City: State Zip Code Phone: Primary medical condition for which Medical Marijuana is requested: Cachexia Anorexia Wasting Syndrome Severe pain Severe Nausea Seizures Severe or persistent muscle spasms Glaucoma Post traumatic stress disorder (PTSD) Chronic pain Please describe when this condition started: Other Medical Problems and/or Symptoms Please describe any previous tests (X-rays, CT scan, MRI, EMG etc) or treatments (Surgery, Injections, Medications and Therapy etc) you have had for the treatment of this/these conditions: Please describe what makes the symptoms worse: sitting standing rest heat cold walking exercise other Please describe what makes the symptoms better: sitting standing rest heat cold walking exercise other Page 1 of 5
2 Eastern Shore MediCann Clinic, LLC Past Medical History: Please note if you have had any of the following Medical Problems Arthritis Anxiety Chronic Pain Depression Diabetes Head Injury Heart Disease High Blood Pressure Hepatitis C Hyperthyroid Kidney Disease Liver Disease Multiple Sclerosis Osteoporosis Seizures Sleep Apnea Stroke Ulcers Gout Lupus Rheumatoid Arthritis Other Surgical History: Please note if you had any surgeries and write date of each surgery None Surgery Date: Are you pregnant? Yes No Unsure Date of last menstrual period: Allergies: None Medication allergy: Food Family History: Please write if anyone in your immediate family has any of the following illnesses: None/don t know Alcoholism Arthritis Depression Cancer Multiple Sclerosis Drug Use Diabetes Bipolar disorder Heart Disease Parkinsonism Rheumatoid Arthritis Lupus Gout Other Medications: Please list ALL medications/herbs you are taking. Use back of this page if needed. Medications/Supplements Dosage How long have you been taking this medication? Functional History: How do your symptoms affect your daily activities? Do you use any assisted devices? No Cane Walker Crutches Wheelchair Other comments or concerns you wish to address with the physician? Page 2 of 5
3 Eastern Shore MediCann Clinic, LLC Review of Systems Checklist: (please check all that apply to your current condition) General Head Eyes Weight loss or gain Headache Vision loss/changes Fatigue Head injury Glasses or Cataracts Fever or chills Neck pain Pain Weakness Trouble sleeping Nose Stuffiness Discharge Itching Hay fever Nosebleeds Sinus pain Throat Bleeding Dentures Sore tongue Dry mouth Sore throat Hoarseness Thrush Non-healing sores Neck Lumps Swollen glands Pain Stiffness Breasts Lumps Pain Discharge Self-exams Breast-feeding Respiratory Cough Sputum Coughing up blood Shortness of breath Wheezing Painful breathing Cardiovascular Chest pain or discomfort Tightness Palpitations Shortness of breath with activity Difficulty breathing lying down Swelling Sudden awakening from sleep with shortness of breath Gastrointestinal Swallowing difficulties Heartburn Change in appetite Nausea Change in bowel habits Rectal bleeding Constipation Diarrhea Yellow eyes or skin Redness Flashing lights Glaucoma Cataracts Urinary Urgency Burning or pain Blood in urine Change in urinary strength Vascular Calf pain with walking Leg cramping Musculoskeletal- Muscle or joint pain Stiffness Back pain Redness of joints Swelling of joints Trauma Neurologic Dizziness Fainting Seizures Weakness Numbness Tingling Tremor Hematologic Ease of bruising Ease of bleeding Endocrine Head or cold intolerance Sweating Frequent urination Psychiatric Nervousness Depression PTSD Page 3 of 5
4 Eastern Shore MediCann, LLC Social History: Are you currently employed? Yes No What type of work If you are no longer working why did you stop and do you expect to return to work? Are you on disability? (start date) On workmen s compensation?(start date) Are you? Married Single Divorced Widowed/Widower Smoking History: no ex-smoker current Drinking History: no ex-drinker current Drug Use: no current past cocaine marijuana heroin Other Have you ever been addicted to prescription drugs Yes No Psychiatric History: no Have you ever seen a psychiatrist psychologist social worker Cannabis History: Are you currently using marijuana? Yes No When did you start? Frequency of Use : daily weekly monthly Delivery System: pipe joint vaporizer tincture food Have you had any adverse effects from cannabis? yes no if yes, anxiety insomnia depression paranoia other Does cannabis provide relief from your medical symptoms/problem? yes no Pain Questionnaire: Where is your worst pain? How and when did your pain begin? Does your pain radiate? To: R arm L arm R leg L leg other Is the pain: sharp dull burning aching stabbing shooting throbbing cramping electric intermittent steady superficial deep Other Please rate your pain on a scale of 0-10 with 0 being no pain and 10 the worst pain imaginable How long has your pain been at this level? Page 4 of 5
5 Eastern Shore MediCann, LLC On diagram below please mark the areas where you have pain Use the symbols to indicate where your pain is: Moderate Pain = o Severe Pain = x Numbness = N Ache= A L Back R R Side L Side R Front L I believe that my physical and/or mental health will worsen, if I do not have medical marijuana available as self-medication. Agree Do not Agree I consider my medical condition to be debilitating and that my condition is presently progressing to an extent that one or more major life activities (i.e., eating, sleeping, working, socializing) are substantially limited. Agree Do not Agree My signature below attests to the fact that I have read and have accurately completed this form to the best of my knowledge. All information regarding my medical condition and the records I am submitting is completely truthful and represents the medical condition for which I am seeking treatment. I voluntarily consent to this evaluation and understand that I am solely responsible for payment for services. Patient s Signature Date
New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification
Name Social Security Number Address: Street: _ New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification Date of Birth Gender: Male Female City: State Zip Code E-mail: Home Phone:
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
PATIENT INFORMATION FORM
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Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
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Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed
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NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
Health History. Tests and Procedures: Test: Date: Location: Provider: Abnormal: Results/Notes: Monthly self breast exam. Last mammogram (female)
Comprehensive Cancer Center A Cancer Center Designated by the National Cancer Institute Please answer the following questions and bring this form to your first appointment at Rutgers Cancer Institute of
PATIENT MEDICAL HISTORY INTAKE FORM
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SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
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GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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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
Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire Name: MR#:_ Date: Date of Injury: Referred By: Age: Date of Birth: Handed: R L Ambidextrous Male Female **** Mark
New Patient Intake Form
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NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )
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COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM Last Name: First Name: Middle: Home Phone: Other Contact: Other Contact: DOB: Age: Sex: Name of Referring Physician: Phone: Fax: Address: City: State: Zip: Name
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NEW PATIENT INFORMATION
OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
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Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
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ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -
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Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
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New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
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Medical Information. (office use) MRN: CMRN: Last Name: First Name: Middle Initial: Date of birth: Age: Sex: M F Height: Weight:
1835 W. County Rd C, Suite 80, Roseville, MN 55113 P: 651-797-6880 F: 651-797-6881 info@spartzvein.com spartzvein.com Medical Information Date of consultation: (office use) MRN: CMRN: Last Name: First
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
2. Have your symptoms affected your ability to carry out your daily activities? YES NO
QUESTIONNAIRE Page 1 of 5 Date: Referring MD (Name, Address, Phone Number): Primary Care Physician (Name and Address, Phone Number): Reason for visit: 1. How long have you had symptoms? Describe your symptoms?
Medical History Form
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New Patient Medical History Form
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DATE OF BIRTH: MELANOMA INTAKE
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Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
Please fill out this form as completely as possible. This information will determine how we treat your pain problem.
Name Date of birth Age Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your
New Patient Information
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Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
RHEUMATOLOGY PATIENT HISTORY FORM
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Psychiatric Evaluation Intake Form
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CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
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WELCOME to the Florence Chiropractic and Wellness Center.
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
NEW PATIENT QUESTIONNAIRE Spine pt acct #
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PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
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McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
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Florida Hospital Spine Center Patient Intake Form
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TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
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Patient History (Please Print)
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GENERAL INFORMATION HISTORY QUESTIONNAIRE Name: Today s Date: Age: Date of birth: Sex: M F SS#: Home Address: Cell Phone: Your doctor: Home Phone: Your Attorney (if any): If questions arise after today
Cell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
PATIENT HEALTH INFORMATION SHEET
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