Florida Orthopaedic Institute David Watson, M.D. Patient Questionnaire. Patient Name: Date: MR#:
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1 Flrida Orthpaedic Institute David Watsn, M.D. Patient Questinnaire Patient Name: Date: MR#: Primary Physician Infrmatin Family/Primary Physician: Family/Primary Physician address and phne #: Wh referred yu? Patient: Dctr: Friend: Advertising: Other: Marital Status: Handed: Height/Weight Occupatin: single right Height (ft) married left Height (in) divrced bth widwed Age: Sex: Male Female Current Wrk Status: O emplyed O nt wrking O retired O light duty Have yu seen a dctr in the past fr this prblem r injury? If yes, wh and when?
2 GENERAL NEW PATIENT HISTORY CURRENT INJURY/PROBLEM What is the MAIN injury/prblem yu are seeing the dctr fr tday? IF UNLISTED CHOOSE THE CLOSEST. right shulder left shulder head right arm left arm neck right elbw left elbw chest right frearm left frearm midback right wrist/hand left wrist/hand lw back right hip left hip Prblems walking right thigh left leg Weakness, numbness, tingling right knee left knee Other right calf left calf right ft/ankle left ft/ankle If mre than ne injury/prblem, which is wrse? SELECT ONLY ONE IF UNLISTED CHOOSE THE CLOSEST. right shulder left shulder head right arm left arm neck right elbw left elbw chest right frearm left frearm midback right wrist/hand left wrist/hand lw back right hip left hip Prblems walking right thigh left thigh Weakness, numbness, tingling right knee left knee Other right calf left calf right ft/ankle left ft/ankle Date injury/prblem began (APPROXIMATE IF UNSURE): Is yur prblem a result f an injury/prblem? Yes N 2
3 Please describe yur current prblem. IF YOU ARE SEEING THE DOCTOR FOR MULTIPLE PROBLEMS, ANSWER FOR THE MOST SEVERE: New injury r prblem (less than 6 weeks duratin) Subacute prblem (6 week 3 mnths duratin) Chrnic prblem (prblem has been treated ver time perid f mre than 3 mnths and never been restred t nrmal) Re-injury What caused yur injury/prblem? Fall Lifting Thrwing Reaching Pulling Fighting Twisting Sprts Cllisin/Cntact Other If the prblem/injury is a result f an injury, where did it ccur? at hme at wrk via a mtr vehicle accident while exercising at a sprt cmpetitin ther Other cause f injury/prblem: Other: Check any f the fllwing that happened at the time f yur injury/prblem: Felt pain Had swelling Fracture Bruising Heard ppping Dislcatin Defrmity Have yu had surgery related t the prblem yu are being seen fr tday? Yes N 3
4 What cnservative treatment have yu had n r since yur injury/prblem began? Injectin Chirpractic care Aspiratin Bracing Physical Therapy Heat Exercise Ice Anti-inflammatry medicatin Massage Pain medicatin Rest Date yu began cnservative treatment Have yu received nn-surgical treatment fr at least 3 mnths fr this prblem? Yes Yes N N Have yu talked t a lawyer cncerning yur prblem/injury Yes Yes N N PAIN Are yu having pain tday? Are yu receiving r have yu applied fr wrker cmpensatin cncerning yur prblem/injury? Is yur prblem the result f an aut accident? Is yur pain tday: Yes N ccasinal cntinuus/cnstant On a scale f 0-10 (with 10 being the wrst pain imaginable, hw wuld yu scre yur pain tday? D yu have pain that keeps yu awake? never ccasinally frequently What time f day is yur pain wrst? Check the wrks that best describe the character f the pain yu are having tday: mrning aching nagging shting afternn burning numb tender evening exhausting thrbbing unbearable nighttime gnawing sharp all the time miserable stabbing 4
5 What makes yur symptms better? rest sitting sprts/exercise medicatin standing brace/cane/crutch ice walking sleeping heat squatting physical therapy lying dwn stretching injectin nthing in particular Other factr that makes the pain better: What makes yur symptms wrse? lying dwn stping/ pushing bending sitting lifting pulling standing squatting wrking walking stairs nthing in particular sprts/ reaching exercising twisting/pivting verhead activity activity in general Other factr that makes the pain wrse: REVIEW OF SYSTEMS General Eyes ENT & Muth Pulmnary (lungs) nne nne nne nne recent weight gain difficulty recent weight lss appetite change difficulty sleeping seeing Lss f visin duble visin blurred visin difficulty hearing shrtness f breath nse bleeds dry cugh swallwing difficulty Sinus prblems Fevers asthma Prblems walking (balance prblems, falling) Night sweats prductive cugh (sputum) brnchitis sleep apnea 5
6 Gastrintestinal Geniturinary Musculskeletal Hematpietic/Lymphatic N issues N issues N issues N issues heartburn/ burning n urinatin jint pain anemia ingestin difficulty swallwing frequency f urinatin stmach pains difficulty starting urine ulcers wetting pants r nausea/ vmiting bed jint defrmity lymph nde jint swelling r warmth enlargement frequent infectins jint stiffness excessive bleeding bldy urine muscle pain bld clts diarrhea sexual difficulties weakness hemrrhids neck pain rectal bleeding back pain black bwel mvements change in bwel habits Skin Neurlgic N issues N issues Psychiatric cnstipatin ecchymtic headaches N issues frequent laxative purulent drainage dizziness anxiety use (pus) swllen blackuts depressin jaundice r hepatitis liver truble Erythematus (red) numbness and gallbladder prblems Endcrine/Metablic tingling difficulty sleeping rash paralysis appetite changes itching cnvulsin/seizur easy bruising/bleeding es crdinatin truble cnfusin memry lss slw healing been seen by a Cardivascular psychiatrist N issues N issues leg cramps (when walking) diabetes high bld pressure fainting giter chest pain cldness in hands and/r feet thyrid prblem heart attack lss f hair n arms r legs sterility palpitatins (irregular heart beat) abnrmal clr (blue, white, red) in chlesterl / lipid prblem heart failure ther hands r feet 6
7 edema (leg swelling) MEDICAL CONDITION HISTORY Medical Cnditin Histry: NO MEDICAL PROBLEMS Depressin Alchlism Gut Anemia HIV Anxiety Hypertensin (High Bld Pressure) Asthma Hyperchlesterlemia (Elevated Arthritis inflammatry (rheumatid) Arthritis ste, degenerative Chlesterl) Hypthyridism Kidney Disease Bwel disease Liver Disrder (Cirrhsis, Hepatitis) Cancer Lung Disease (COPD, emphysema) Ostemyelitis Cardiac Arrhythmia (Abnrmal heart rate) Cngestive Heart Failure Parkinsn s Crnary Artery Disease (Angina) Cerebrvascular Disease (Strke) Diabetes Ulcer Disease Other Other Medical Cnditin: Have yu ever had a bld clt? Yes N Have yu every had a bld transfusin? Yes N 7
8 SURGERY/PROCEDURES Arthrscpy Fracture Repair right shulder left shulder right shulder left shulder right elbw left elbw right arm left arm right wrist/hand left wrist/hand right elbw left elbw right hip left hip right frearm left frearm right knee left knee right wrist/hand right ft/ankle left ft/ankle right pelvis left pelvis Jint Replacement Surgery right hip right femur (thigh) left wrist/hand left hip left femur (thigh) right shulder left shulder right knee left knee right elbw left elbw right tibia/fibula right wrist/hand left wrist/hand right ft/ankle right hip left hip left tibia/fibula left ft/ankle right knee left knee Spine Surgery right ft/ankle left ft/ankle Cervical Thracic Lumbar Other Orthpedic Surgery Nn Orthpedic Surgeries abdminal surgery brain surgery cancer surgery cardithracic surgery eye surgery gallbladder surgery gyneclgic surgery hernia repair plastic surgery sinus surgery tnsillectmy urlgy surgeries vascular surgery ther Other Surgeries 8
9 FAMILY MEDICAL HISTORY Please check all diseases fr which yu have a family histry: Arthritis, Rheumatid (inflammatry) Dementia Diabetes Strke Other Other diseases: Arthritis, Degenerative Cancer Breast Cancer Prstate Cancer Other Heart Disease High Bld Pressure High Chlesterl Lung Disease 9
10 SOCIAL HISTORY Current Emplyment: Level f Educatin: Exercise: Full Time Grade Schl d nt regularly exercise Part Time High Schl/ Equivalent nce per week Retired Sme Cllege 3-5 times per week Student Cllege Degree daily Unemplyed Disabled Alchl: Graduate Degree Tbacc: Never use alchl I use chewing tbacc Used t drink but stpped I have never smked Rarely drink alchl (<1/mnth) Drink ccasinally (1-4/mnth) tbacc I used t smke tbacc but stpped I currently smke less than ½ pack per day Drink scially (1-2/week) I currently smke ½-1 pack a day Drink frequently (3-5/week) I currently smke 1-2 packs a day Drink daily (1/day) I currently smke mre than 2 packs a day Drugs: D nt use drugs ccaine marijuana ther Other drugs: 10
11 MEDICATIONS AND ALLERGIES Are yu currently taking any medicatins? Yes N Patient Current Medicatins: Medicatin Name Dse Fr what purpse? D yu have any allergies? Yes N Please list all allergies (including idine and cntract dyes): Allergy Severity 1 Mild Mderate Severe 2 Mild Mderate Severe 3 Mild Mderate Severe 4 Mild Mderate Severe 5 Mild Mderate Severe 6 Mild Mderate Severe 7 Mild Mderate Severe 11
12 Pharmacy Name PREFRERRED PHARMACY INFORMATION Pharmacy Street Address City, State, Zip If address unknwn please prvide crssrads Pharmacy Phne Number I acknwledge that everything I have answered is true and crrect t the best f my knwledge. Patient Signature: Date: The abve patient infrmatin has been reviewed by:. Prvider s Signature: Date: 12
Patient Name: Date: MRN:
GENERAL NEW PATIENT HISTRY What is the MAIN injury/problem you are seeing the doctor for today? IF UNLISTED CHSE THE CLSEST. right shoulder pain left shoulder pain head right arm pain left arm pain neck
Urology CHIEF COMPLAINT ALLERGIES. What is the main reason for your visit today? Allergen Yes No Reaction
Urlgy Kari White, NP Phne: 646-962-9600 Name: Date f Birth: Date: CHIEF COMPLAINT What is the main reasn fr yur visit tday? ALLERGIES Are yu allergic t any f the fllwing? Please check YES r NO fr each.
Patient Information Packet Date:
Patient Infrmatin Packet Date: We knw paperwrk is nt fun, but thank yu s much fr taking the time! Last Name: First Name: MI Address: Phne: City State: Zip Cde: Mbile: D.O.B: / / Scial Security: / / Email:
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Phne: 262-248-6700 Fax: 262-248-6764 Email: inf@excelfamilychir.cm Patient Name: Date: Address City/State Zip Cde Hme. Phne Cell: Wrk. Email Address: Sex: M F (Please circle) Date f Birth: Referred by:
Do you have any of the symptoms listed below? Please circle all that apply.
D yu have any f the symptms listed belw? Please circle all that apply. Parkinsn s Symptms: Truble walking Falls Feet sticking t the flr Tremr Medicatins wearing ff Truble sleeping Vivid dreams Thrashing
New Patient Information Sheet PLEASE COMPLETE THIS ENTIRE FORM. Date of Appointment: / /
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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:
BROCKTON AREA MULTI-SERVICES, INC. MEDICAL PROCEDURE GUIDE. Date(s) Reviewed/Revised:
Page 1 f 6 Subject: Range f Mtin Exercises Date Develped: 4/2010 PROTOCOL FOR: All trained staff PURPOSE: Range f Mtin (ROM) exercises are very imprtant if an individual has t stay in bed r in a wheelchair.
Last Name First Name Middle Name MRN
Dr. Byers Dr. Su Dr. Sponzilli Lisa Elvin, NP Spine Center New Patient Form Last Name First Name Middle Name MRN This form is used to gather information so that my doctor can maximize the time used to
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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
Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?
Gregory H. Tchejeyan, M.D., Inc. Please fill out this form in its entirety. Please complete every line item, as it is necessitated by regulations from the government (Health Care Finance Administration
SPINE PROGRAM NEW PATIENT FORM
Name: Date of Birth: Today s Date: Are you right or left handed? What are your goals for the visit? Who referred you to us? Primary Doctor Another Doctor Dr. Of what specialty? Someone else: PAIN 1. Tell
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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:
MEDICATION GUIDE Pioglitazone and Metformin Hydrochloride (PYE o GLI ta zone and met FOR min HYE-droe- KLOR-ide)Tablets, USP
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Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD
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Patient Name: Date of Birth:
Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
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List the health concerns that brought you into this office
New Practice Member Applicatin Name Date f Birth / / Age Male/Female Address City State Zip Cell Phne Hme Phne Cellular Prvider Email Address Occupatin Emplyer s Name Single / Married / Divrced / Widwed
Headache Follow-up Visit Form
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FLORIDA RTHOPAEDI."i OINSTITUTEC
FELLOWSHIP TRAINE SURGICAL Sl,I BSPECIALISTS Foot & Ankle Hand & Wrist Interventional Spine Joint Replacement Oncology Shoulder & Elbow Spine Surgery Sports Medicine Trauma & Fracture ear Patients, FLORIA
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Patrick J McGahan, MD Orthopaedic Surgeon Specializing in Sports Medicine/Shoulder Reconstruction Surgery Instructions Hip
Patrick J McGahan, MD Orthpaedic Surgen Specializing in Sprts Medicine/Shulder Recnstructin 2801 K St, Ste 330, Sacrament, CA, 95816 (p) 916-733-5049 (f) 916-733-8914 www.patrickmcgahanmd.cm Befre Surgery
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Who is filling the form (name & relation): Date: Referred by: Ethnicity: Present height: Name of mother: Name of father:
Pnam Patel, B.Sc., N.D. Dctr f Naturpathic Medicine PEDIATRIC INTAKE FORM Please print clearly and fill ut this frm t the best f yur ability. It will help t assess the child s present health and will assist
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM Which Chiropractor are
454-8 (Insert) MEDICATION GUIDE ZUBSOLV (Zub-solve) (buprenorphine and naloxone) Sublingual Tablet (CIII) IMPORTANT: Keep ZUBSOLV in a secure place
MEDICATION GUIDE ZUBSOLV (Zub-slve) (buprenrphine and nalxne) Sublingual Tablet (CIII) IMPORTANT: Keep ZUBSOLV in a secure place away frm children. Accidental use by a child is a medical emergency and
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
MEDICATION GUIDE Pioglitazone (pie-oh-glit-ah-zohn) and Metformin (met-fore-min) Hydrochloride Tablets USP
MEDICATION GUIDE Piglitazne (pie-h-glit-ah-zhn) and Metfrmin (met-fore-min) Hydrchlride Tablets USP Read this Medicatin Guide carefully befre yu start taking piglitazne and metfrmin hydrchlride tablets
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
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Myrtle Grove Chiropractic & Acupuncture Center
FOR OFFICE USE ONLY Myrtle Grve Chirpractic & Acupuncture Center C BC/BS MC MD AA O WELCOME TO YOUR HEALTH HAPPINESS & HOPE CLINIC TODAY S DATE: PURPOSE OF APPOINTMENT: CONSULTATION TREATMENT OTHER HOW