Chad J Anderson D.C.
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- Randolf McGee
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1 Chad J Anderson D.C. New Patient Health History Form NAME: DATE: / / DOB: / / AGE: MARITAL STATUS: M / S / D / W ADDRESS: CITY: STATE: ZIP: PHONE: CELL PHONE: EMERGENCY CONTACT: PHONE#: RELATIONSHIP: REFERRED BY: OCCUPATION (IF RETIRED, FORMER OCCUPATION): EMPLOYER: CURRENT MD: PAST CHIROPRACTIC CARE? Y / N DR S NAME: Please answer the following questions on this page if you have a current open Worker s Comp or Personal Injury Case. (IF YOU DO NOT HAVE AN OPEN CASE PLEASE GO TO PAGE 2) Date of onset: Body part injured: Who is the worker s compensation carrier?
2 What is the reason you are seeking Chiropractic care today? Primary Condition? Secondary Condition? Third Condition? What caused the symptom(s)? Date the symptom(s) began? Instructions: Please circle the word or number that best answers the question being asked. Did the symptom(s) start: Suddenly? Gradually? Over how long of period? Is the symptom(s) getting: Better? Worse? Same? What percentage (%) of the day is your symptom(s) present? 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100 Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst. Example: HEADACHE NECK LOW BACK NO PAIN WORST POSSIBLE PAIN 1. What is your pain level right now? No Pain Worst Possible Pain 2. What is your typical average pain level (in a 24 hour period)? No Pain Worst Possible Pain 3. What is your pain level at its least (how close to zero 0 does the pain level get)? No Pain Worst Possible Pain 4. What is your pain level at its worst (how close to ten 10 does the pain level get)? No Pain Worst Possible Pain
3 On the Body Drawing below, mark where your pain is at describing the pain with the following letters: A= Achy Pain B= Burning Pain D= Dull Pain N= Numbing Pain S= Sharp Pain T= Traveling/Radiating Pain Is/Are your symptom(s) worse at a certain time of day? Y / N Morning, Noon, Afternoon, Evening, Night-Time Have you had this symptom before? Y / N (If No, go to page 4) If Yes; When was it before? (Approx. Date, or Year) Did you seek care? Y / N who did you see? What was the outcome? (Please Circle): Resolved, Better, No Change, Worse, Needed Surgery, Other If other; what was the outcome?
4 WHAT MAKES THE SYMPTOM(S) WORSE? (PLEASE CHECK ALL THAT APPLY) Motion of the HEAD Head Down Turning Left Tilting Left Head Up Turning Right Tilting Right Motion of the Low Back Bending Forward Twisting Left Side Bend Left Bending Backwards Twisting Right Side Bend Right ACTIVITIES: (THAT YOU CANNOT DO OR IS PAINFUL TO DO) Standing Dressing Driving Sitting House Work General Working Getting out of a Chair Yard Work Reading Sit to Stand Bending TV / Computer Putting on Socks Lifting Walking Sleeping Grooming Other If other, please describe: What makes the symptom(s) Better? (Less) Nothing Walking Prescription Meds Ice Sitting OTC Pain Meds Heat Laying Down Topical Gels Resting Stretching Other If Other, please describe: Please describe the quality of the symptom(s). Check all that apply! Dull Achy Pin-Needle Burning Spasm Sharp Throbbing Numbing Shooting Pressure
5 Past Medical History (Illness, Fractures Past and Current) Past Surgical History Allergies Medications (Please List) Name of Medication Reason Prescribed
6 Social History: Smoker Y / N Past Smoker Y / N Year Quit Tobacco Y / N Alcohol Y / N Children Exercise Days/Week Type Hobbies Family Health History (Only Health History of your Parents, Grandparents, and Siblings Needed) Cancer Heart Disease RA Strokes Migraines MS Parkinson s _ Women Only Are you currently Pregnant Y / N Date of last menstrual cycle If YES, Due Date # of Pregnancies Pregnancy outcomes: Natural birth C-Section Still Born Aborted Breast Augmentation Surgery Y / N Pelvic Inflammatory Disease Y / N Endometriosis Y / N Fibroids Y / N
7 Low Back Disability Questionaire (Revised OSWESTRY) Instructions: This questionnaire has been designed to enable us to understand how your back pain has affected your ability to manage your everyday activities. Please answer each section by marking the ONE CHOICE that most applies to you. We realize you may feel that more than one statement may relate to you. PLEASE JUST MARK THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YUR PROBLEM RIGHT NOW Section 1 Pain Intensity o I can tolerate the pain without having to use painkillers o The pain is bad, but I can manage without having to take painkillers o Painkillers give me complete relief from pain o Painkillers give me moderate relief from pain o Painkillers give very little relief from pain o Painkillers have no effect on the pain and I do not use them Section 2 Personal Care (Washing, Dressing, etc) o I can look after myself normally without causing extra pain o I can look after myself normally but it causes extra pain o It is painful to look after myself and I am slow and careful o I need some help but manage most of my personal care o I need help every day in most aspects of self-care o I do not get dressed, I wash with difficulty and stay in bed Section 3 Lifting o I can lift Heavy weights without extra pain o I can lift heavy weights but it causes extra pain o Pain prevents me from lifting weights off the floor, but I can manage if they are conveniently positioned, ie on a table o Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. o I can lift very light weights o I cannot lift anything at all Section 4 Walking o Pain does not prevent me from walking any distance o Pain prevents me from walking more than one mile o Pain prevents me from walking more than one-half mile o Pain prevents me from walking more than one-quarter mile o I can only walk using a stick, cane, or crutches o I am in bed most of the time and have to crawl to the toilet Section 5 Sitting o I can sit in any chair as long as I like o I can only sit in my favorite chair for as long as I like o Pain prevents me from sitting more than one hour o Pain prevents me from sitting for more than 30 minutes o Pain prevents me from sitting for more than 10 minutes o Pain prevents me from sitting all of the time Section 6 Standing o I can stand as long as I want without extra pain o I can stand as long as I want but it causes extra pain o Pain prevents me from standing more than 1 hour o Pain prevents me from standing more than 30 minutes o Pain prevents me from standing more than 10 minutes o Pain prevents me from standing at all Section 7 Sleeping o Pain does not prevent me from sleeping well o I can sleep well only by taking medication o Even when I take medication I sleep less than 6 hours o Even when I take medication I sleep less than 4 hours o Even when I take medication I sleep less than 2 hours o Pain prevents me from sleeping at all Section 8 Social Life o My social life is normal and gives me no extra pain o My social life is normal but it increases the degree of pain o Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing o Pain has restricted my social life and I do not go out as often o Pain has restricted my social life to my home o I have no social life because of my pain Section 9 Traveling o I can travel anywhere without extra pain o I can travel anywhere but it causes extra pain o Pain is bad but I manage journeys over 2 hours o Pain is bad but I manage journeys less than 1 hour o Pain restricts me to short necessary journeys under 30 minutes o Pain prevents me from traveling except to the doctor or hospital Section 10 Changing Degree of Pain o My pain is rapidly getting better o My pain fluctuates but overall is definitely getting better o My pain seems to be getting better but the improvement is slow at best o My pain is neither getting better nor worse o My pain is gradually getting worse o My pain is rapidly getting worse
8 Review of Systems: Have you had any of the following health issues? (write C for current, P for past) 1. Pulmonary Asthma COPD Emphysema 2. Endocrine Hormonal Replacement Diabetes Steroid Shots Thyroid Disease Adrenal Insulin Pump 3. Dermatomal (skin) Significant Burns Significant Rashes Skin Grafts Psoriasis Melanomas Skin Cancer Plastic Surgery 4. Neurological (Nerve) Vision Loss Lost Strength Lost Feeling Seizures Headaches Memory Loss Tremors Tremors Lost Smell Lost Taste Dizziness Vertigo 5. Hematological (Blood) Anemia Anti-Inflammatory use (OTC, Aleve, Aspirin) HIV/AIDS Bleeding/Bruising Sickle-Cell Anemia Large Lymph Nodes Hemophilia Blood Clots Phlebitis 6. Cardiovascular (Heart) Heart Attack Heart Surgery Stroke Congestive Heart Failure TIA s Angina Irregular Heart Beat High Blood Pressure High Cholesterol Heart Murmer Mitral Valve Replacement 7. Renal (Kidney) Kidney Stones Blood in Urine Bladder Control Bladder Infections Dialysis Hard to Urinate Kidney Disease 8. Gastroenterological (Digestion) Nausea Hard to Swallow Ulcerative Colitis Abdominal Pain Hiatal Hernia Constipation Gall Stones Pancreatic Disease IBS Heart Burn Bowel Incontinences 9. Musculo-Skeletal (Muscle and Bone) Rheumatoid Arthritis Gout Osteoarthritis Osteopenia Osteoporosis Bone Fractures Spinal Fractures Spinal Surgery Scoliosis Metal Implants
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COOK CHIROPRACTIC CLINIC 1715 S MAIN ST KANNAPOLIS NC 28081 704-938-7111 FX:704-932-4066 Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address Line
*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
*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
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / / Email Address: Do not have email Do not wish to provide Date of Birth: / / Gender: Male
OhioHealth Orthopedic & Sports Medicine Physicians
Page 1 of 6 OhioHealth Orthopedic & Sports Medicine Physicians 335 Glessner Avenue, Mansfield, Ohio 44903 PATIENT INTAKE ASSESSMENT OFFICE USE ONLY Fax to: OR Control 419-520-2831 For Joint Replacement
PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: Internet: Fax:
PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: 412-221-7640 Internet: www.davidprovenzanomd.com Fax: 412-490-9850 301 Ohio River Boulevard, Suite 203 Edgeworth Medical Commons Sewickley, PA 15143 INITIAL
New Patient Intake Form. Please List All Current Medications. Please shade in the areas where you have pain
New Patient Intake Form Name: Date: Referring Physician Primary Care Physician Please List All Current Medications Do you take Coumadin/Warfarin/Plavix/Lovonox or Aspirin? Yes No Last dose? Please shade
Patient Data Sheet. Emergency Contact Name: Relationship: Contact phone number: Name: Specialty: Office address: Office phone: Fax:
Today s Date: / / Your Information Patient Data Sheet Last ame: First: MI: Sex: M F Date of Birth: / / Age: SS: Address: Home phone: Cell phone: Can we leave message on Home? Y or Cell? Y Are you currently
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Date of Birth Age Address City State Zip NATURE OF ACCIDENT: 1. Date of Accident Time of Day (AM / PM) 2. Please state how the accident happened in your own words: 3.
CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:
JOSE G. VELIZ MD, INC. Diplomate of the American Board of Interventional Pain Management Diplomate of the American Board of Anesthesiology Diplomate of the American Board of Pain Medicine Fellow of Interventional
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
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
\ NSMI. The National Sports Medicine InstJtute
~ \ NSMI The National Sports Medicine InstJtute 19455 Deerfield Avenue Su ite 3 12 Lansdowne, Virgin ia 20 I76 24430 Stone Spring Blvd, Suite 250, Dulles, Virginia 20166 Patient Information: Last Name:
SPINE AND ORTHOPEDIC PAIN CENTER, P.C. WINIFRED D. BRAGG, M.D.
SPINE AND ORTHOPEDIC PAIN CENTER, P.C. WINIFRED D. BRAGG, M.D. PATIENT INFORMATION Patient Name (Last, First, Middle Initial) Home Address Gender (M/F) Phone (Home) City State Zip code Phone (Work) Marital
Pain Clinic Packet Neal E. Coleman, MD Andrew Trobridge, MD Angelia Huffmeyer, FNP J. Mark Hannaford, PA Matthew Stinson, PA-C
Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your
Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)
Patient s Name: Date: What is the reason for your visit today? Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone #
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
Robert J. Brownsberger, M.D., PC New Patient Paperwork
1 Today s Date: Robert J. Brownsberger, M.D., PC New Patient Paperwork Your Name: Date of Birth: SS#: Email: Race/Ethnicity: Primary Language: Mailing address: Home Phone: Cell Phone: Preferred Pharmacy:
Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician
Current Problem Date Name (First, MI, Last) Date of Birth Age Male Female Primary Care Physician Referring Physician Height (feet/inches) Weight (lbs.) Right Handed Left Handed Both Current Problem: Right
Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business