NEW PATIENTS' INFORMATION SHEET
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- Alice Franklin
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1 NEW PATIENTS' INFORMATION SHEET Please print clearly. Please complete all information so that your claim can be processed quickly and efficiently. Thank you! PATIENT INFORMATION (First) (MI) (Last) Name Date of Birth: Sex: Male / Female Marital Status: S M W D (Street) (City) (State) (ZIP) Address: Home Phone #: Cell Phone#: Social Security #: Employer: Work #: Employer's Address: If Student, School Name: Full / Part Time Emergency Contact: Phone #: Relationship: Do you have an Advance Directive or Living Will? Yes (please provide copy) No WORKER'S COMP/ACCIDENT INFORMATION Insurance Name: Address: Phone #: ( ) - Adjuster Name: Adjuster Phone #: ( ) - Date of Injury or Accident: Claim #: Type of Injury: Back Leg Hip Neck Shoulder Arm Head Other: Place of work during time of accident: Phone #: ( ) - In Litigation: Yes NO Amount of Medical Benefits: Notice of Compensation Payable: Yes NO
2 INSURANCE INFORMATION Insurance Co.: Phone #: Insurance Address: Identification #: Group #: Insured's Name: Relationship to Patient: Self / Spouse / Dependent Insured's Employer: Phone #: Employer's Address: Insured's Social Security #: Date of Birth: Sex: Male / Female If the patient is covered by another insurance policy, please complete the following information for coordination of benefits. This information will enable your insurance company to process your claim more quickly. Thank you! INSURANCE INFORMATION Insurance Co.: Phone #: Insurance Address: Identification #: Group #: Insured's Name: Relationship to Patient: Self / Spouse / Dependent Insured's Employer: Phone #: Employer's Address: Insured's Social Security #: Date of Birth: Sex: Male / Female I hereby assign, transfer, and set over to Center for Pain Control all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. Patient's Signature Date
3 1235 Penn Ave, Suite 302, Wyomissing, PA Phone: Fax: Jason T. Bundy, MD Karen A. Kerns, PA-C Nicole L. Harper, PA-C April E. Palmer, NP-C Martha Decembrino, RN, MAc DATE: NAME: DOB: REFERRING PHYSICIAN: FAMILY DOCTOR: PLEASE COMPLETE THESE FORMS PRIOR TO YOUR APPOINTMENT AND BRING THEM WITH YOU THE DAY OF YOUR SCHEDULED APPOINTMENT. If you are unable to fill them out yourself, please have your family doctor give you a list of your medical history and current medication. You will need to arrive at our clinic 30 min prior to your appointment so we can assist you with this form. What is your chief complaint? (example: 30% low back pain and 70% right leg pain) When did it start? (example: 2months ago, or ) Did you sustain any trauma immediately prior to the onset? YES NO Is this work related or motor vehicle accident related? YES NO Do you have an attorney? (Please provide their contact information) YES NO Please describe the trauma. Is the pain there constantly, intermittently, or both? (example: constant back pain with intermittent left leg pain) Please describe the characteristics of your pain. (sharp vs. dull, burning, squeezing, throbbing, tingling, etc.) What makes the pain worse? (Please circle) Sitting Standing Walking Lying flat Bending over Lifting Others What makes the pain better? (Please circle) Sitting Standing Walking Lying flat Lifting Change Positions Other Taking medications (please list )
4 What have you tried? Ibuprofen (Advil, Motrin) Acetominophen (Tylenol) Naproxen (Aleve, Naprosyn) Diclofenac (Voltaren) Nabumetone (Relafen) Meloxicam (Mobic) Celecoxib (celebrex) Other NSAID Carisoprodol (Soma) Cyclobenzaprine (Flexeril, Amrix) Metaxalone (Skelaxin) Tizanidine (Zanaflex) Other Muscle Relaxant Gabapentin (Neurontin) Pregabalin (Lyrica) Topiramate (Topamax) Amitriptyline (Elavil) Duloxetine (Cymbalta) Venlafaxine (Effexor) Nortriptyline (Pamelor) Hydrocodone/APAP (Vicodin, Lortab, Norco) Oxycodone/APAP (Percocet, Endocet, Tylox, Roxicet) Methadone Morphine Fentanyl patch Oxycontin Lidoderm Patches Flector Patches Voltaren Gel Medrol Dosepak Other medications Dosage? How long? Helpful? Reason stopped Chiropractors Massage therapy Physical therapy / Aquatic therapy Tens Unit Heat Compress Cold compress Acupuncture therapy Psychotherapy / Biofeedback Behavior modification therapy How long? Helpful? Reason stopped
5 Images (X-Ray, CT Scan, Bone Scan, etc.) Study Date Where Spine Injections Epidural steroid inj Facet injections Radiofrequency ablations SI joint injections Doctor Date Helpful? How long did it last? Spine surgery Doctor Date Helpful? How long did it last? Current Medication (Please list ALL medications including vitamins and OTC meds) Medication Why prescribed Dosage Are you allergic to any medications? (Please list and describe reaction) Medication Reaction IV contrast allergy? YES NO Shellfish allergy? YES NO
6 Past Medical History (Please circle all) AIDS / HIV Alcoholism Asthma Cancer Diabetes Emphysema Epilepsy Heart Disease Hepatitis Herpes High Blood Pressure Multiple Sclerosis Pacemaker Seizures Stroke Thyroid Disorders Tuberculosis Fibromyalgia Depression Bipolar Disorder Schizophrenia Anxiety Disorder Other Psychiatric Issues Irritable Bowel Syndrome Chronic Pelvic Pain Migraine Other: Past Surgical History Surgery Year Family History (Please list all significant family medical history such as bleeding problems (hemophilia), psychiatric disorders, chronic pain, or any substance abuse) Social history Who do you live with now? Do you have any children? How many? How is their health? Are you currently working? If not, why not? When did you stop? What do/did you do for a living? Do you smoke? If yes, how much? (per day on average) Do you drink? If yes, how much? (per day on average) Do/did you use any illicit drugs? What kind and how much? Have you ever gone through rehab for drug or alcohol abuse?. Are you currently pregnant or plan to become pregnant? YES NO Have you ever been discharged from a doctor s office because of noncompliance not following their directions? Review of system In the past month, have you experience any significant (Please circle all) Weight loss/gain Fever/chills Changes in hearing/vision Dizziness Pass out Shortness of breath Productive cough Chest pain Abdominal pain Diarrhea/constipation Weakness in the extremities Lost control of bowel/urinary functions Bleeding problems Rashes Depression Suicidal thoughts Homicidal thoughts Others
7 Please shade in on the drawings the areas where you feel pain. R L L R L R Please rate the severity of your pain (mark baseline and with exacerbation ) BASELINE WITH ACTIVITY 10 9 worst pain imaginable 10 9 worst pain imaginable no pain 0 no pain Who has treated you since the onset of the chief complaint? Patient's Signature Date
NEW PATIENT INFORMATION SHEET
Akintomi A. Olugbodi M.D. 301 S. Seventh Ave. Suite 315 West Reading, PA 19611 (484) 869-2817 NEW PATIENT INFORMATION SHEET PLEASE COMPLETE THESE FORMS PRIOR TO YOUR APPOINTMENT AND BRING THEM WITH YOU
Initial Pain Questionnaire
Initial Pain Questionnaire Date: Name: Address: Last First Middle Initial Street Address City State Zip Home Phone Cell : Work: Referring Physician: Other Physicians: Age: PAIN HISTORY: What is the main
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:
DOB Age Sex Weight Height Right Handed Left handed
Lee Ann Brown, D.O. Date: Patient Name DOB Age Sex Weight Height Right Handed Left handed Marital Status S M D W Is your problem related to: Car /Bike accident Yes/No Date Slip or Fall accident Yes/No
PAIN INFORMATION SHEET
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We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
NEW PATIENT QUESTIONNAIRE
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PATIENT REGISTRATION FORM
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Chiropractic Case History/Patient Information
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Using the symbols below, please draw in the location of your symptoms on the diagrams. X = Pain 0 = Numbness / = Aching * = Pins & Needles
Date: DOB: Age: Gender: Right handed: Left handed: Who referred you? Is your problem related to : Job injury Date: Car accident Date: Date: Briefly describe your main problem/complaint. Also, describe
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