Using the symbols below, please draw in the location of your symptoms on the diagrams. X = Pain 0 = Numbness / = Aching * = Pins & Needles
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- Lee May
- 5 years ago
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1 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 the injury that caused these symptoms. Using the symbols below, please draw in the location of your symptoms on the diagrams. X = Pain 0 = Numbness / = Aching * = Pins & Needles If you have NECK PAIN, what percentage of your pain is % Neck versus %Arm (must total 100% i.e. 70/30) If you have BACK PAIN, what percentage of your pain is % Back versus % Leg (must total 100% i.e. 90/10) Mark an X on the line indicating the usual degree of your pain (0 means No pain, 10 means Worst pain) LEAST WORST Patient Name:
2 If today's visit is a result of a MOTOR VEHICLE ACCIDENT: Date of the accident: Did you lose consciousness? YES NO Were you the: Driver Passenger Have you had headaches? YES NO Vehicle impact was: Rear Side Front Did you have head trauma? YES NO Did you go to the E.R. after the accident? YES NO Wearing a seatbelt? YES NO How much damage was done to your vehicle? $ If today's visit is a result of a WORK RELATED INJURY: Date of the accident: Work status: Were you: Light duty Twisting Full duty Reaching overhead Off duty per provider Lifting and twisting Unable to work since injury Lifting Slipped and fell Had a motor vehicle accident The onset of your pain began: The course of your pain has been: Acute Increasing Decreasing Gradual Improving Worsening Sudden Gradually worsening Gradually improving Gradual/sudden following a motor vehicle accident Rapidly worsening Rapidly improving Gradual/sudden following no specific incident Constant Without change Variable Variable The pattern of your pain is: Persistent Intermittent Episodic The duration of your pain symptoms has been: Minutes Hours Days Weeks Months Years The severity of your pain has been: Mild Moderate Severe Constant with degrees of severity How would you characterize your pain: Dull Ache Burning Throbbing Numbness (check all that apply) Pins & Needles Cramping Electrical Shooting Catching Tingling Your pain is mainly located where: If your pain travels, where does it start and end: If you get numbness and tingling, please describe where: How long can you stand with no or minimal pain: Minutes Walking distance with no or minimal pain: 0-50 ft ft ft ft 1/2 mile+
3 Have you had any recent: Progressive weakness Bowel or bladder incontinence Fever Chest pain Nausea Vomiting Medical changes Night sweats Has your activity level: Stayed the same Increased Decreased Please check below what makes your pain worse or better: Position/Activity Worse Same Better N/A Worse Same Better N/A Bending Bowel movement Coughing General activity Home remedies Lying down Sitting Standing Walking Aggr/Relieve Sympt Worse Same Better N/A Worse Same Better N/A Ice TENS units Heat Injections Exercise Manipulation Medication Acupuncture Physical therapy Botox Bed rest Whirlpool Ultrasound Pool exercise Do you need SUPPORT to help you walk? YES NO If yes, what kind of support? Do you wear a back or neck BRACE? YES NO If yes, what kind of brace? WORK STATUS: Full duty Light duty Off duty per provider Unemployed Retired If you are NOT working full duty: How long have you been off work? Have you had a work capacity assessment? YES NO Are you disabled through Social Security? YES NO If yes, then for what illness? Indicate which DIAGNOSTIC TESTS you have had in evaluation of your main complaint/problem (include dates). Test Date Test Date Test Date Plain X-ray Bone scan Myelogram EMG/NCS/SSEP Arthrogram MRI CT scan Dexa scan Discogram List below the PREVIOUS PROVIDERS (MD, DO, CHIROPRACTOR, PA-C, CNP) you have seen for your main complaint. Provider Specialty Dates Treatment
4 Have you taken any of the following drugs previously? Medication Helpful? Medication Helpful? Medication Helpful? Amitriptyline Opana Motrin Cymbalta Oxycodone Naprosyn Gabapentin Tylenol #3 Prednisone Lyrica Tramadol Voltaren gel Nortriptyline Savella Prozac Tylenol Topamax Zoloft Lidoderm patch Baclofen Butrans Aspirin Carisoprodol Demerol Celebrex Cyclobenzaprine Dilaudid Etodolac Methacarbamol Duragesic Flector patch Skelaxin Hydrocodone Ibuprofen Tizanidine Morphine Meloxicam Valium DRUG ALLERGIES Drug Type of reaction List ALL CURRENT MEDICATIONS as follows Name Dose (mg/gram) How often per day How long PAST MEDICAL HISTORY Bowel disorders Cancer (where?) Depression Diabetes Heart disease High blood pressure High cholesterol Kidney disease Lung disease Check below if you have had any of the following Comments Multiple myeloma Osteoporosis Pacemaker Psoriasis Rheumatoid arthritis Serious infection Stroke Thyroid Ulcers Comments List any SURGERY(S) you have had Type Date Outcome
5 SOCIAL HISTORY & HABITS Occupation Marital status Highest education level TOBACCO USE Do you currently use Tobacco products? YES NO Started Age/Year Stopped If yes, indicate the quantity per day: Cigarettes Cigars Chewing tobacco (snuff) ALCOHOL USE Do you currently consume alcoholic beverages? YES NO If yes, indicate the quantity per day: Beer Wine Distilled spirits Have you ever been treated for drug or alcohol addiction? YES NO REVIEW OF SYSTEMS Check if you have experienced any of the following CONSTITUTIONAL EYES, EAR, NOSE, THROAT RESPIRATORY Weight gain-last 6 mo Recent changes in vision Short of breath Weight loss-last 6 mo Night sweats Chills Fever Dizziness Wheezing GASTROINTESTINAL GENITO-URINARY CENTRAL NERVOUS SYSTEM Nausea Blood in urine Poor appetite Vomiting Diarrhea Indigestion Abdominal pain Bloody or dark stools CARDIOVASCULAR Chest pain Palpitations Short breath w/exercise Heart murmur Feet edema Recent changes in hearing Recent changes in smell Recent changes in taste Urinary tract infections Unable to control bladder Unable to control bowel Rushing to go Need to go frequently MUSCULOSKELETAL Cramps Attack of weakness Join pain/swelling Morning stiffness Back pain Cough Sputum History of tuberculosis Problem sleeping Numbness/tingling feet Numbness/tingling hands Crying spells Convulsions Easy bleeding Any rashes Easy bruising SKIN FAMILY HISTORY RELATION MOTHER FATHER SIBLINGS: #1 #2 #3 #4 #5 AGE HEALTH PROBLEMS
DOB Age Sex Weight Height Right Handed Left handed
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Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
WESTERN NEUROSURGICAL CLINIC MEDICAL EVALUATION QUESTIONNAIRE. Name: Date of Birth. Age: Social Security No.: Driver's Lic.# Occupation: Employer:
Date: IDENTIFICATION: WESTERN NEUROSURGICAL CLINIC MEDICAL EVALUATION QUESTIONNAIRE Name: Date of Birth Age: Social Security No.: Driver's Lic.# Occupation: Employer: ******************************************************************************
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
Numbness: o o o o o. Grade your overall pain. Pain Rating Scale Mosby. Worst Possible Pain. No Pain HURTS LITTLE MORE HURTS EVEN MORE
Patient Name: Original Referring Physician: Current PCP: PAIN DIAGRAM Is your condition the result of a: Work injury? YES NO Auto accident? YES NO Date of Injury: / / Please mark the areas of discomfort
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)
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
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:
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. If you already completed this form in the last 3 months, please fill
* 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
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