New Patient Paperwork
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- Carol Harper
- 6 years ago
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1 New Patient Paperwork Your Name: Today s Date _ Height: Weight: lbs Pharmacy Name: Phone Number: Onset of Symptoms and Reason for Visit Today Use the diagram below to indicate the location and type of your pain. Mark the drawing with the following letters that best describe your symptoms: N umbness P ins and Needles A ching S tabbing B urning What is your current pain level right now? What is your worst level of pain level? Where is your worst area of pain located? Does the pain radiate? If yes, where? Please list additional areas of pain When did this pain begin? What caused your current pain or injury? Was the pain or injury due to a motor vehicle accident or personal injury? Yes No How did your current pain episode begin? Gradually Suddenly Since your pain began, has your pain Increased Decreased Stayed the Same What word best describes the frequency of your pain? Constant Intermittent When is your pain at its worst? Mornings During the Day Evenings Middle of Night 1 Page Revised June 26,2017
2 Check all that describe your pain TODAY - Aching Hot/Burning Shooting Stabbing/Sharp Tiring/Exhausting Cramping Numb Spasming Throbbing Dull Shock-like Squeezing Tingling/Pins and Needles Diagnostic Tests & Imaging - Mark all of the following tests you have had related to your current pain: MRI of the Date: Facility: X-ray of the Date: Facility: CT scan of the Date: Facility: EMG/NCV study Date: Facility: Other I HAVE NOT HAD ANY DIAGNOSTIC TESTS PERFORMED FOR MY CURRENT PAIN COMPLAINTS Pain Treatment History - Mark the following pain treatments you have undergone PRIOR to today s visit: Treatment No Relief Moderate Relief Excellent Relief Biofeedback Bracing Chiropractic Decompression Therapy Epidural Steroid Injection Home Exercise Program Medial Branch Blocks or Facet Injections Medications, please check which ones below - Topical Cream Anti-inflammatories Muscle Relaxants Nerve Pain Medications Physical Therapy, how many sessions Radiofrequency Ablation Rest Spine Surgery Spinal Column Stimulator Trial Permanent TENS Unit Trigger Point Injections Other Treatments: I HAVE NOT HAD ANY PRIOR TREATMENTS FOR MY CURRENT PAIN COMPLAINTS Other Physicians you have seen to treat your pain Acupuncturist Neurosurgeon Orthopedic Surgeon Pain Physician Physical Therapist Primary Care Provider Psychiatrist/Psychologist Rheumatologist Neurologist Other 2 Page Revised June 26,2017
3 Factors that Affect your Pain Increases Pain Decreases Pain No Change Bending Backward Bending Forward Changes in Weather Climbing Stairs Coughing/Sneezing Driving Lifting Objects Looking Forward Looking Downward Looking Side to Side Rising from a Seated Position Sitting Standing Walking What other factors worsen or affect your pain that is not listed above? Current Medications Are taking a prescribed blood-thinner or aspirin, if so, which one? Name/phone number of the doctor that prescribes your blood thinner Please list ALL medications you are currently taking. Attach an additional sheet if required. Medication Name Dose Frequency Medication Name Dose Frequency Activity How many days a week do you exercise? Type of Exercise: Bicycle Cardio Strength Swimming Walking Other Have you had two or more falls in the past year? Yes No 3 Page Revised June 26,2017
4 Allergies - Please list all allergies that you have, DO NOT LIST SIDE AFFECTS Medication Name that I m Allergic to: 1) 2) 3) 4 Page Revised June 26,2017 The Allergic Reaction I have is: 4) 5) Are you allergic to any of the following? Iodine Yes No Tape Yes No Latex Yes No Do you require special rescue measures for your latex allergy? Yes No No Known Allergies Family History - Mark all appropriate diagnoses as they pertain to your BIOLOGICAL family members only. Anxiety/Depression High Blood Pressure Arthritis Kidney Problems Cancer Liver Problems Diabetes Rheumatoid Arthritis Headaches Seizures Heart Disease/Stroke Substance Abuse I HAVE NO SIGNIFICANT FAMILY MEDICAL HISTORY Abdominal Surgery: Gallbladder removal Appendectomy Female Surgeries Caesarean section Hysterectomy Laparoscopy Ovarian Heart Surgery Valve replacement Aneurysm repair Stent placement Joint Surgery Shoulder Hip Knee I AM ADOPTED (No Medical History Available) Past Surgical History - Please indicate all surgical procedures you have had done, including the date Spine / Back Surgery Discectomy (levels) Laminectomy Spinal fusion (levels) Other Common Surgeries Hemorrhoid surgery Hernia repair Thyroidectomy Tonsillectomy Vascular surgery Please list any other surgeries and dates (attach an additional sheet if necessary): I HAVE NOT HAD ANY SURGICAL PROCEDURES DONE
5 Past Medical History /Problem List - Mark all conditions/diseases that you have been DIAGNOSED with: Cardiovascular / Hematologic Anemia/Bleeding Disorders Coronary Artery Disease Heart Attack High Blood Pressure Hypertension High Cholesterol Mitral Valve Prolapse Pacemaker/Defibrillator Poor Circulation Stroke Gastrointestinal Bowel Incontinence Acid Reflux (GERD) Gastrointestinal Bleeding Constipation General Medical Cancer Type Diabetes Type HIV / AIDS Genitourinary/Nephrology Bladder/Kidney Infection(s) Dialysis Kidney Stones Kidney Disease Liver Disease Urinary Incontinence Hepatic list active inactive unsure Hepatitis A B C active inactive unsure Head/Eyes/Ears/Nose/Throat Glaucoma Headaches Head Injury Hyperthyroidism Hypothyroidism Migraines Musculoskeletal Amputation/ Phantom Limb Pain Bursitis Carpal Tunnel Syndrome Fibromyalgia Joint Injury Osteoarthritis/Osteoporosis Rheumatoid Arthritis Vertebral Compression Fracture Respiratory Asthma Bronchitis Emphysema / COPD Tuberculosis Valley Fever Neuropsychological Alzheimer Disease Anxiety/Depression Bipolar Disorder Depression Epilepsy Multiple Sclerosis Paralysis Peripheral Neuropathy Schizophrenia CRPS/Reflex Sympathetic Dystrophy Other Diagnosed Conditions: I HAVE NO SIGNIFICANT MEDICAL HISTORY Current Past surgical Medical Medications history History - Mark Please all list of ALL the medications conditions and/or you are diseases currently that taking. you have Attach been additional treated for sheet in the if required. past: Social History Alcohol Use: Current Alcoholism History of Alcoholism Never Drinks Alcohol Social Alcohol Use Smoker or Tobacco Use: Current User Former User Never Marijuana Use: Current User Former User Never Medical Marijuana Card Holder Drug Use: I Deny Any Illegal Drug Use I am Currently Using Illegal Drugs, list: I am Currently Using Someone Else s Prescription Medications, list I Formerly Used Illegal Drugs (not currently using); list I Have Abused Narcotic or Prescription Medications, list 5 Page Revised June 26,2017
6 Global Pain Scale Please answer all questions INSTRUCTIONS: For each question, please indicate your response by circling a number from 0 to 10 YOUR PAIN: 0 = No Pain 10 = Extreme Pain During the past week, the best my pain has been is During the past week, the worst my pain has been is During the past week, my average pain has been During the past 3 months, my average pain has been YOUR FEELINGS: During the past week I have felt: 0 = Strongly Disagree 10 = Strongly Agree Afraid Depressed Tired Anxious Stressed YOUR CLINICAL OUTCOMES: During the past week: 0 = Strongly Disagree 10 = Strongly Agree I had trouble sleeping I had trouble feeling comfortable I was less independent I was unable to work (or perform normal tasks) I needed to take more medication YOUR ACTIVITIES: During the past week I was NOT able to: 0 = Strongly Disagree 10 = Strongly Agree Go to the store Do chores in my home Enjoy my friends and family Exercise (including walking) Participate in my favorite hobbies Page Revised June 26,2017
7 Review of Systems - Mark all of the following symptoms that you CURRENTLY suffer from: Cardiovascular/Respiratory: Chest Pain Cough Difficulty Breathing Fainting High Blood Pressure Swelling in the Feet Constitutional: Chills Difficulty Sleeping Fatigue Fevers Night Sweats Ears/Nose/Throat/Neck: Difficulty Hearing Earaches Hay fever/allergies Nosebleeds Recurrent Sore Throats Ringing in the Ears Sinus Problems Family History of Substance Abuse: Alcohol Illegal Drugs Prescription Drugs Personal History of Substance Abuse: Alcohol Illegal Drugs Prescription Drugs Eyes: Recent Visual Changes Gastrointestinal: Constipation Dark and Tarry Stools Diarrhea Nausea/Vomiting Genitourinary/Nephrology: Blood in Urine Involuntary Urination Loss of Bowel Control Painful Urination Pelvic Pressure Musculoskeletal: Back Pain Joint Pain Neck Pain Mark Each that Applies Neurological: Dizziness Headaches Instability When Walking Numbness/Tingling Weakness Psychiatric: Anxiety/Stress Depressed Mood Suicidal Thoughts Suicidal Planning item Score If Female OFFICE USE ONLY Item Score if Male Your Age (Mark box if 16-45) 1 1 Personal History of Preadolescent Sexual Abuse: 3 0 Personal History of Psychological Disease: Attention Deficit Disorder, OR Obsessive Compulsive Disorder, OR Bipolar, OR Schizophrenia Depression 1 1 None of the above apply to me TOTAL 7 Page Revised June 26,2017
8 Medical History and Consent for Treatment I certify that the above information is accurate, complete and true. I authorize Arizona Pain and any associates, assistants, and other health care providers it may deem necessary, to treat my condition. I understand that no warranty or guarantee has been made of a specific result or cure. I agree to actively participate in my care to maximize its effectiveness. In the event that I am asked to provide a urine, oral swab and/or blood sample, I voluntarily seek laboratory services and hereby consent to provide a urine, oral swab and/or blood sample as requested. I have the right to refuse specific tests, but understand this may impact my pain management treatment. This agreement can be revoked by me at any time with written notification and is valid until revoked. I give my consent for Arizona Pain to retrieve and review my medication history. I understand that this will become part of my medical record. I give my consent for Arizona Pain to retrieve and review my medication history. Signed: Patient or Guardian or Patient Representative Date: Printed Name: ***** Please continue to the next page to complete your demographic information, thank you***** 8 Page Revised June 26,2017
9 Patient Demographic Information Patient Name: Date of Birth: Social Security Number - - Gender: Male Female Street Address: City/State/Zip: Physical Address Same as Mailing? Yes No If not, please list mailing address: Preferred Phone: Home Mobile Work Secondary Phone: Home Mobile Work Emergency Contact Name: Phone: Relationship: Patient Primary Insurance Plan Payer (example BC/BS): Plan: Policy/I.D. Number: Group Number: Complete this box if you are not the policy holder for your primary insurance Insurance policy holder: Self Spouse Child Other: Policy Holder Name: Date of Birth: Policy Holder Gender: Female Male Social Security Number: Secondary Insurance Plan (if any) Payer (e.g. BC/BS): Policy/I.D. Number: Plan: Group Number: Complete this box if you are not the policy holder for your secondary insurance Insurance policy holder: Self Spouse Child Other: Policy Holder Name: Date of Birth: Policy Holder Gender: Female Male Social Security Number: 9 Page Revised June 26,2017
10 Workers Compensation Claim Information Complete this section only if your visit today is related to a Workers Compensation claim Workers Comp Company: Agent Name: State of Injury: Phone number: Claim Number: Fax number: Date of initial injury: Injury Claim Is your pain the result of a Motor Vehicle Accident or Personal Injury? (legal term describing injury sustained to your person by negligence of another) Yes No If yes, you will be asked to complete a separate form Certification I certify that the above information is accurate, complete and true. I understand that this will become part of my medical record. Signed: Patient or Guardian or Patient Representative Date: Printed Name: 10 Page Revised June 26,2017
New Patient Paperwork
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Robert J. Brownsberger, M.D., PC New Patient Paperwork
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Beno Kuharich, D.O. Interventional Spine/Pain
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Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency 1 2 3 4 5 6 7 8 9 10 11 12 13
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
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PAIN INFORMATION SHEET
PAIN INFORMATION SHEET PLEASE MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE SENSATIONS DESCRIBED BELOW. PLEASE USE THE APPROPRIATE SYMBOL & INCLUDE ALL AREAS. **** ==== OOOO XXXX //// ACHE **** NUMBNESS
* CC* PATIENT QUESTIONNAIRE
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USE THIS DIAGRAM TO INDICATE THE LOCATION AND TYPE OF YOUR PAIN
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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:
New Patient Intake Form
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Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#
Date Name / / last first middle initial Personal Health # - Male Female Home Address City Postal Code Home Telephone # Business Telephone # Cell # E-Mail Address Best way to contact you: Home # Work #
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
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COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
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Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
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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
History of Present Problem
Patient Name: Date: If you are not the patient: Guardian name: Relationship to Patient: Height: Ft In Weight: lbs Age: Birth Date: Dominant Hand: Right Left Shoe Size: Primary Care Physician: Specialists:
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:
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CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
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
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
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If not, q Home q Mobile q Work
New Intake Paperwork Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best care possible. Please
RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118
Patient Health History Full Name Date Street Address City & State Zip Phone Number Gender Date of Birth Age SSN How did you hear about our office? Marital Status # of Children? Currently Pregnant? / How
New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification
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PLAS/RECON SURGERY PATIENT HEALTH HISTORY
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NEW PATIENT QUESTIONNAIRE Spine pt acct #
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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
Florida Hospital Spine Center Patient Intake Form
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The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C
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NEW PATIENT INFORMATION
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J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
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Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
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PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM NAME: D.O.B AGE: SEX: STREET: CITY: STATE: ZIP: SS #: ETHNICITY: RACE: LANGUAGE: PHONE # TO LEAVE A PERSONAL MESSAGE: HOME PHONE #: WORK #: CELL #: E MAIL ADDRESS: EMERGENCY CONTACT:
Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me
Today s : MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: I am a Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code: Home #: Work #: Cell