Do not write in this box. Name: Appointment: Date: Appointment Time: Primary Care Provider: Phone: Fax: Referring Physician: Address:
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1 3901 Rainbow Boulevard Do not write in this box Appointment: Date: Appointment Time: Birth date: Age: Gender: Male Female Primary Care Provider: Phone: Fax: Referring Physician: Address: Phone: Fax: CHIEF COMPLAINT: Mark the areas on your body where you feel the described sensations using the symbols below: Stabbing Burning Numbness Pins & Needles Ache //// ==== oooo XXXX AAA SPN-010 Page 1 of 6
2 Do not write in this box 3901 Rainbow Boulevard HISTORY OF PRESENT ILLNESS: When did your pain start? Where is your pain? Have you been given a diagnosis for your pain? No Yes Explain: Was there a mechanism of injury (eg. fall, MVA, heavy lifting)? No Yes Please explain injury: Is this work related? No Yes Date of injury: Is the pain constant or does it come and go? Check the words that best describe the quality of your pain: Aching Stabbing Nagging Burning Throbbing Gnawing Numb-like Tiring Shooting Penetrating Sharp Unbearable What makes the pain better? (eg.rest, sitting down, ice, heat, medications): What makes the pain worse? (eg.sit, stand, walk, bend): How long can you sit stand walk before the pain occurs? Does the pain radiate into your arm or leg? No Yes How Far? Explain: Do you have numbness or weakness in your arm or leg? No Yes Explain: Have you lost control of bladder or bowel function? No Yes Explain: Is the pain worse at night? No Yes Explain: SPN-010 Page 2 of 6
3 Do not write in this box 3901 Rainbow Boulevard PAIN SCALE: Circle the pain level on a scale of 0 to 10, with 10 being unbearable or worst imaginable pain to describe your pain today: How bad is your low back pain? Average pain level in the past week (rate 0-10): How bad is your leg or foot pain? How bad is your middle back pain? How bad is your neck or upper back pain? How bad is your arm or hand pain? TESTS FOR THIS CONDITION: Test: Date (mo/yr) Facility (hospital/clinic) X-ray CT scan MRI Discogram Myelogram EMG/NCV s Other Results TREATMENTS FOR THIS CONDITION (Check appropriate box for amount of relief): Treatment: No Relief: Some Relief: Good Relief: Physical Therapy Chiropractic Care Injections Surgery Medication: Medication: Medication: Other SPN-010 Page 3 of 6
4 3901 Rainbow Boulevard Do not write in this box PAST : Please check all that apply and check condition or specify Heart problems: angina heart attack murmur valve disease Vascular: high blood pressure stroke varicose veins blood clots in legs, or in lungs Lung disease: Asthma COPD emphysema pneumonia Digestive: stomach ulcers diverticulitis irritable bowel Crohn s Endocrine disorders: diabetes (insulin or no) low or high thyroid Liver disease: Hep A Hep B Hep C cirrhosis Infectious disease: HIV/AIDS Kidney disease: stones recurrent bladder infection renal insufficiency Blood disorders: anemia leukemia Eye disorders: glaucoma cataracts Cancer (specify type): Neurologic disorders: headaches epilepsy nerve injury seizures Psychiatric disorders: depression anxiety ADHD PAST SURGICAL HISTORY: MAJOR INJURIES/HOSPITALIZATIONS: CURRENT MEDICATIONS (other than your pain medicines): Are your taking a blood thinner? No Yes ALLERGIES (include medications, latex, and others): SPN-010 Page 4 of 6
5 Do not write in this box 3901 Rainbow Boulevard SOCIAL HISTORY: Single Married Separated Divorced Widow/Widower Do you have children? No Yes How many? Who lives with you? Are you working or retired? What is your current job? Does your job require manual labor? No Yes Explain: Do you have any special needs? No Yes Explain: Are you on disability or SSI? No Yes Explain: Do you drink alcoholic beverages? No Yes What kind? How often do you drink alcohol? Do you smoke cigarettes? No Yes Chew tobacco? No Yes If you smoke cigarettes, how many packs per day? How many years? Do you now or have you ever used any of the following drugs? No Yes Substance/Drug Amphetamine Barbituates Cocaine Heroin Marijuana Others, specifiy: Have you ever been in treatment for alcohol abuse: No Yes Drug abuse? No Yes If yes, explain: Is there pending litigation related to your injury/pain? No Yes Explain: FAMILY Has any direct relative had the same condition for which you are being seen for today? No Yes Explain: My mother is: Deceased living at age years and is in good health or suffers from My father is Deceased living at age years and is in good health or suffers from If any direct relative has any of the following conditions, please indicate: Arthritis/joint pain Back or neck pain Bleeding disorders Cancer(list type) Diabetes Heart/lung problems High Blood Pressure Osteoporosis Stroke If other disorders, please list: SPN-010 Page 5 of 6 Rev. 9/09
6 3901 Rainbow Boulevard Do not write in this box REVIEW OF SYSTEMS: Please check all conditions that apply that were not given in past medical history. Constitutional: None Fever Chills Sweats Weight gain Weight loss Loss of appetite Eyes /Ears/Nose: None Eye, ear, nose problems Blurred vision Hearing loss Difficulty swallowing Cardiovascular: None Chest pain Fluttering in heart Angina Respiratory: None Short of breath Productive cough Pneumonia Gastrointestinal: None Diarrhea Constipation Bowel Incontinence Cirrhosis Nausea/vomiting Blood in stool Genitourinary: None Urine incontinence Painful urination Blood in urine Urinary urgency Endometriosis Musculoskeletal: None Joint pain Back pain Skin: None Skin rash Hives Blisters Eczema Psoriasis Neurological: None Weakness Loss of balance Headache Dizziness Numbness Psychiatric: None Depressed mood Excessive worry Sleep disorders Drug or alcohol abuse Endocrine: None Heat or cold intolerance Hematologic: None Bleeding problems Swollen nodes Easy bruising Allergic: None Seasonal allergies Hay fever Reviewed by Physician: Date: PEDIATRIC SCOLIOSIS: This section is to be completed by patients 18 and under being seen for scoliosis. 1. When was your scoliosis first detected? 2. Explain how your scoliosis was detected: Parent/patient School screening School physical 3. Age of onset of menstruation (girls only): 4. Family members with scoliosis:
7 5. Growth in the last year: SPN-010 Page 6 of 6
8 3901 Rainbow Boulevard CENTER OSWESTRY QUESTIONNAIRE Do not write in this box This questionnaire is designed to give us information as to how your symptons (i.e. back, let, neck or arm) have affected your ability to manage in everyday life. Please answer every section. Mark one box only in each section that most closely describes you today. 1 Pain Intensity 2 Personal Care (washing, dressing, etc.) I have no pain at the moment. I can look after myself normally without causing extra pain. The pain is very mild at the moment. I can look after myself normally but it is very painful. The pain is moderate at the moment. It is painful to look after myself and I am slow and careful. The pain is fairly severe at the moment. I need some help but manage most of my personal care. The pain is very severe at the moment. I need help every day in most aspects of self care. The pain is the worst imaginable at the moment I do not get dressed, wash with difficulty and stay in bed. 3 Lifting 4 Walking I can lift heavy weights without extra pain. Pain does not prevent me from walking any distance. I can lift heavy weights but it gives me extra Pain prevents me from walking more than 1 mile. pain. Pain prevents me from lifting heavy weights off Pain prevents me from walking more than ½ of a mile. the floor but I can manage if they are conveniently positioned, e.g. on a table. Pain prevents me from lifting heavy weights but Pain prevents me from walking more than 100 yards. I can manage light to medium weights if they are conveniently positioned. I can lift only very light weights. I can only walk using a stick or crutches. I cannot lift or carry anything at all. I am in bed most of the time and to have crawl to toilet. 5 Sitting 6 Standing I can sit in any chair as long as I like. I can stand as long as I want without any pain. I can sit in my favorite chair as long as I like. I can stand as long as I want but it gives me extra pain. Pain prevents me from sitting for more than 1 hr Pain prevents me from standing for more than 1 hr Pain prevents me from sitting for more than ½ Pain prevents me from standing for more than ½ hr hr Pain prevents me from sitting for more than 10 Pain prevents me from standing for more than 10 minutes min. Pain prevents me from sitting at all. Pain prevents me from standing at all. 7 Sleeping 8 Sex life (if applicable) My sleep is never disturbed by pain. My sex life is normal and causes no extra pain. My sleep is occasionally disturbed by pain. My sex life is normal but causes some extra pain. Because of pain I have less than 6 hours sleep. My sex life is nearly normal but is very painful. Because of pain I have less than 4 hours sleep. My sex life is severely restricted by pain. Because of pain I have less than 2 hours sleep. My sex life is nearly absent because of pain. Pain prevents me from sleeping at all. Pain prevents any sex at all. 9 Social Life 10 Traveling My social life is normal and causes me no extra pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. sports. Pain has restricted my social life and I do not go out as often. Pain has restricted my social life to my home. I can travel anywhere without pain. I can travel anywhere but it gives me extra pain. Pain is bad but I manage journeys over two hours. Pain restricts my journeys of less than one hour. Pain restricts me to short necessary journeys under 30 min.
9 I have no social life because of pain. Pain prevents me from traveling except to receive treatment. OSWESTRY QUESTIONNAIRE SPN /08
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Samuel A. Joseph, Jr., M.D. Your appointment has been scheduled: Your appointment time is: Please arrive at: o o o 2727 West Dr. Martin Luther King Jr. Blvd. Suite 590 Tampa, FL 33607 1840 Mease Drive
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
New Patient Intake Form
New Patient Intake Form Please complete information below Name: DOB Age Male Female Referring Physician FAX Address Phone _ Primary Care Physician FAX Address Phone Is this a work related problem? If yes,
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Dr. Edwards New Patient Paperwork Please fill out these forms completely
Dr. Edwards New Patient Paperwork Please fill out these forms completely Date of Appointment Complete the enclosed packet and bring it to the appointment along with all X Rays, MRI disc and reports. Please
AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C. 2407 Lenora Church Road / Snellville, Georgia 30078-6916 / 770-979-2731 Welcome to our office! Today's Date: / / Your Name: [ ] Male [ ] Female What
Pain Drawing. Name: Today s Date: How were you referred to the office: Visual Analog Scale
Pain Drawing Name: Today s Date: How were you referred to the office: Please be sure to fill this out as accurately as possible. This will become part of your permanent medical record and will be used
Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
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
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
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
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight:
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight: I Referring Doctor Complete Name of Referring Doctor Last Complete Address
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Corner on Wellness Chiropractic Center Therapeutic Massage
Corner on Wellness Chiropractic Center Therapeutic Massage Patient Name Date Address _ City State Zip Phone Email Emergency Contact Name Phone Employer Work Phone Date of Birth Social Security # Is condition
1607 Visa Dr, Ste 1A 408 E College Ave, Ste C Normal, IL Normal, IL 61761
Normal, IL 61761 Normal, IL 61761 Full Name Address City State Zip Home Phone Cell Email How do you prefer to be contacted? Text Home, Cell, or Work Phone Email Text Reminders Yes No Who can we thank for
Please describe, in detail, when the symptoms began:
161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On
DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State
Patient information Today s Date Patient s Name D.O.B Street Address Apt. No. City / State / Zip Code Home Phone # Work Phone # Social Security # DL # State Sex Female Male Marital Status Single Married
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