CHRISTIANA SPINE CENTER NEW PATIENT QUESTIONNAIRE
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- Lionel Gibson
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1 CHRISTIANA SPINE CENTER NEW PATIENT QUESTIONNAIRE NAME Today s Date CHIEF COMPLAINT _ (Please use your pen to mark painful areas) Front Back Date of Birth When did the pain begin: Allergies and reaction: dye/contrast allergy iodine allergy Smoking History: never currently quit - when packs/day years smoked History of: Substance abuse Alcohol abuse Currently working? No Yes Type Full-time Part-time Disability Retired Is your pain accident related? No Yes Date Motor Vehicle Industrial/Work Do you have a lawyer representing you? No Yes Name Previous Spine Surgery: No Yes Surgeon Name and Date: Physical Therapy: No Yes Aquatic Therapy Bracing TENS unit Alternative Medicine: Chiropractic Acupuncture Massage Therapy Hand Dominance: right left Height: Weight: Medications: (please list names and doses) Past Surgical History: (please list surgeries and dates) Past Medical History: Past Family History: Medical problems: Mother age Medical problems: Father age
2 NAME Date of Birth REVIEW OF SYSTEMS Please circle any medical concerns that you have TODAY: Constitutions: Eyes: Ears, nose, throat: Cardiovascular: Respiratory: Gastrointestinal: Genitourinary: Musculoskeletal: Skin: Neurological: Psychological: Endocrine: Hematology: Allergy/Immune: weight change, weakness, fatigue, fever vision, glasses pain, tearing, double vision hearing, tinnitus, vertigo, pain, sinus, cold, sore throat high blood pressure, murmurs, shortness of breath, chest pain, palpations cough, sputum, coughing up blood, sneezing, asthma, chest pain, bronchitis trouble swallowing, heartburn, vomiting, diarrhea, indigestion, pain blood in stool pain with urination, urinating at night, blood in urine, urgency, hesitancy, incontinence joint pain/stiffness, cramps, back of neck ache, weakness, loss of range of motion, low back pain, thoracic pain rash, lumps, itching, dryness, color change, hair changes, nail changes fainting, blackouts, seizures, paralysis, weakness, numbness, memory loss nervousness, tension, mood changes, depressions, anxiety heat or cold intolerance, sweating, thirst, hunger, changes in urination bruising, bleeding, transfusion reactions drug, product or allergies, immunizations Provider Signature: Anthony L. Cucuzzella, MD, Tony R. Cucuzzella, MD, Anton Delport, MD, Elva Delport, MD, J. Rush Fisher, MD, Ann Kim, MD, Nancy Kim, MD, Michael R. Murray, MD, Scott Roberts, MD, Frank Sarlo, MD, Rebecca Barnett, APRN, Amy Bolstein, PA-C, Jennifer Brown, PA-C, Amanda Farina, APRN, Meghan Malloy, PA-C Disclaimer The Christiana Spine Center, LLC, is a separate name-only entity and does not have separate liability coverage. Physiatrist Associates, PA, employs all physicians and they are not considered partners, employees, agents and/or servants of the Christiana Spine Center, LLC. Pharmacy name and address: Pharmacy phone:
3 CHRISTIANA SPINE CENTER Patient Name: Date: Oswestry Disability Questionnaire (FOR BACK PAIN ONLY) This questionnaire has been designed to give us information as to how your neck pain is affecting your ability to manage in everyday life. Please answer by checking one box in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem. Section 1: Pain Intensity I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the moment Section 2: Personal Care (washing, dressing) I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but can manage most of my personal care I need help every day in most aspects of self-care I do not get dressed, wash with difficulty and stay in bed Section 3: Lifting I can lift heavy weights without extra pain I can lift heavy weights but it gives me extra pain Pain prevents me lifting heavy weights off the floor but I can manage if they are conveniently placed i.e. on a table Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned I can only lift light weights I cannot lift or carry anything Section 4: Walking * Pain does not prevent me walking any distance Pain prevents me from walking more than 1 mile Pain prevents me from walking more than 0.5 miles Pain prevents me from walking more than 0.25 miles I can only walk using a stick or crutches I am in bed most of the time Section 5: Sitting I can sit in any chair as long as I like I can only sit in my favorite chair as long as I like Pain prevents me sitting more than one hour Pain prevents me from sitting more than 30 minutes Pain prevents me from sitting more than 10 minutes CHRISTIANA SPINE CENTER Pain prevents me from sitting at all Section 6: Standing I can stand as long as I want without extra pain I can stand as long as I want but it gives me extra pain Pain prevents me from standing more than 1 hour Pain prevents me from standing for more than 30 minutes Pain prevents me from standing for more than 10 minutes Pain prevents me from standing at all Section 7: Sleeping My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain I have less than 6 hours sleep Because of pain I have less than 4 hours sleep Because of pain I have less than 2 hours sleep Pain prevents me from sleeping at all Section 8: Sex Life (if applicable) My sex life is normal and causes no extra pain My sex life is normal but causes some extra pain My sex life is nearly normal but is very painful My sex life is severely restricted by pain My sex life is nearly absent because of pain Pain prevents and sex life at all Section 9: Social Life My social life is normal and gives 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 i.e. 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 have no social life because of pain Section 10: Traveling 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 me to journeys of less than one hour Pain restricts me to short necessary journeys under 30 minutes Pain prevents me from traveling except to receive treatment
4 Patient Name: Date: Disability Questionnaire (FOR NECK PAIN ONLY) This questionnaire has been designed to give us information as to how your neck pain is affecting your ability to manage in everyday life. Please answer by checking one box in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem. Section 1: Pain Intensity I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the moment Section 2: Personal Care (washing, dressing) I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but can manage most of my personal care I need help every day in most aspects of self-care I do not get dressed, wash with difficulty and stay in bed Section 3: Lifting I can lift heavy weights without extra pain I can lift heavy weights but it gives me extra pain Pain prevents me lifting heavy weights off the floor but I can manage if they are conveniently placed i.e. on a table Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned I can only lift light weights I cannot lift or carry anything Section 4: Work I can do as much work as I want I can only do my usual work, but no more I can do most of my usual work, but no more I can t do my ususal work I can hardly do any work at all I can t do any work at all Section 5: Headaches I have no headaches at all I have slight headaches that come infrequently I have moderate headaches that come infrequently I have moderate headaches that come frequently I have severe headaches that come frequently I have headaches almost all the time I have a fair degree of difficulty concentrating I have a lot of difficulty concentrating I have a great deal of difficulty concentrating I can t concentrate at all Section 7: Sleeping I have no trouble sleeping My sleep is slightly disturbed for less than 1 hour My sleep is mildly disturbed for up to 1-2 hours My sleep is moderately disturbed for up to 2-3 hours My sleep is greatly disturbed for up to 3-5 hours My sleep is completely disturbed for up to 5-7 hours Section 8: Driving I can drive my car without neck pain I can drive as long as I want with slight neck pain I can drive as long as I want with moderate neck pain I can t drive as long as I want because of moderate neck pain I can hardly drive at all because of severe neck pain I can t drive my car at all because of neck pain Section 9: Reading I can read as much as I want with no neck pain I can read as much as I want with slight neck pain I can read as much as I want with moderate neck pain I can t read as much as I want because of moderate neck pain I can t read as much as I want because of severe neck pain I can t read at all Section 10: Recreation I have no neck pain during all recreational activities I have some neck pain with all recreational activities I have some neck pain with a few recreational activities I have neck pain with most recreational activities I can hardly do recreational activities due to neck pain I can t do any recreational activities due to neck pain Section 6: Concentration I can concentrate fully without difficulty I can concentrate fully with slight difficulty
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MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Please complete this form before your Doctor visit. We will review this together and make any changes needed.
1 Medical History Please complete this form before your Doctor visit. We will review this together and make any changes needed. Name Date of Birth Date of visit What is your height? weight? Medical History,
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
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
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
New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification
Name Social Security Number Address: Street: _ New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification Date of Birth Gender: Male Female City: State Zip Code E-mail: Home Phone:
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: May we leave a
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Email Address: May we leave a message? Home Work Cell PLEASE DO NOT LEAVE A MESSAGE Marital
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
COMPREHENSIVE NEW PATIENT QUESTIONNAIRE
What brings you in today? What do you prefer to be called (nickname)? Please list all of your medical conditions. 1. 5. 2. 6. 3. 7. 4. 8. What surgical or medical procedures have you had in the past? 1.
NEW PATIENT REGISTRATION FORM
NEW PATIENT REGISTRATION FORM (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Ethnicity: Hispanic Non-Hispanic Mr. Mrs. Ms. Miss Is this your legal name? If not, what is your legal
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
New Patient Questionnaire HIP Adult Reconstruction & Joint Replacement
New Patient Questionnaire HIP Adult Reconstruction & Joint Replacement Name: DOB: Date: Height: Weight: Age: Chief Complaint Laterality Left Right Both Please describe your symptoms: (Mark all that apply)
PAIN TREATMENT CENTER
PAIN TREATMENT CENTER Name Date Age Occupation Referring Doctor Have you ever been a patient of a Pain Clinic or Center? Yes No If yes where: When did you first notice symptoms of your pain problem? Date
/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address: