PATIENT HISTORY FORM. Patient Name: Date of Birth AGE: Primary Care Provider:
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1 Date: PATIENT HISTORY FORM Patient Name: Date of Birth AGE: Primary Care Provider: What medical problem brings you to our clinic? When did this begin? What do you think caused it? (Circle One) Work Injury Auto Accident Other Please describe (For Auto accidents/work Injury, please complete Auto Accident/WorkInjury Form) Social History: Marital Status: Single Married Divorced Widowed Separated Employment (Please Circle) Employed Student Self-Employed Homemaker Retired Unemployed If employed where: How Long in this position What is your job title? What are your specific duties? Exercise: Type: Frequency: How many Alcohol drinks do you have per week? Do you smoke? Yes No How many packs/day? Do you use street drugs? Yes No Do you use Marijuana? Yes No Medicinal or Recreational How much What Type? (Circle One) Smoke Edible Hash Oil 1
2 Please list all medications you are currently taking Do you take any blood thinning medications such as: Aspirin, Coumadin/Warfarin, Aggrenox, Effient, Lovenox, Plavix, Pletal, Pradaxa, Eliquis, Xarelto, Treutal, etc. yes or no, If yes, Which one Prescribing MD Medication name and dose: Frequency: Do you have any known drug allergies? List medication and reactions: Topical Allergies: Iodine Latex Tape Previous Diagnostic exams Which body part? Date completed Facility imaging done at? MRI CT Scan X-ray Past Medical History (Circle all that apply) Musculoskeletal: Back Pain Chronic Neck Pain Raynaud s phenomenon Bursitis Costochondritis Reflex sympathetic dystrophy Carpal tunnel syndrome Fibromyalgia Scoliosis Cervical disc syndrome Muscular dystrophy Spinal stenosis Chronic Joint Pain Osteoarthritis Trigger finger Chronic musculoskeletal pain Osteoporosis Vertebral compression fracture 2
3 Neurology: Alzheimer s Head Injury Neuropathy Syncope Bell s Palsy Headache Parkinson s disease Trigeminal Neuralgia Cerebral Palsy Multiple Sclerosis Epilepsy Psychiatry: Anxiety Drugs abuse (illegal drugs) Posttraumatic stress disorder Hyperactivity disorder Drug abuse (prescription drugs) Schizophrenia Bipolar disorder Insomnia Suicidal Attempt Chronic Fatigue Syndrome Obesity Depression Obsessive-compulsive disorder Rheumatology: Fibromyalgia Lupus Myasthenia Gravis Gout Mixed Connective tissue disease Rheumatoid Arthritis Respiratory: Asthma Emphysema Pulmonary hypertension Chronic bronchitis Pneumonia Sleep apnea COPD Pneumothorax Spontaneous Tuberculosis Cystic Fibrosis Pulmonary edema Tuberculosis Diffuse interstitial lung disease pulmonary embolism Cardiovascular: Aneurysm Deep vein thrombosis Myocardia infarction Angina Heart Block, complete Myocarditis Aortic Stenosis Heart Block, 2 nd degree Palpitations Atrial fibrillation High Cholesterol Pericarditis Atrial flutter High Triglycerides Peripheral vascular disease Atrial sepal defect Hypertension Syncope Congestive heart failure Murmur Varicose Veins Coronary artery disease Mitral valve prolapse Gastroenterology: Appendicitis Gastritis Liver abscess Cirrhosis Gastro esophageal Reflux Pancreatitis Constipation Hemorrhoids Peptic Ulcer Disease Cohn s disease Hepatitis Gallbladder Disease Jaundice Genitourinary: Bladder Incontinence Nephrolithiasis Urinary tract infection Erectile dysfunction Renal failure Hydrocele Urinary incontinence 3
4 Endocrine: Addison s disease Grave s disease Thyroid nodule Crushing s disease Hyperthyroidism Diabetes Hypothyroidism Infectious Disease: AIDS Herpes Measles Cellulitis Influenza Meningitis Hepatitis Lyme Disease Pneumonia Surgical History: Adenoidectomy Cataract surgery: Left Right Hip Replacement: Left Right Amputation Which Limb: Colectomy Hysterectomy Angioplasty Colon resection Knee replacement: Left Right Appendectomy Coronary artery bypass graft Laminectomy Arthroscopy Fistula repair Mastectomy Biopsy (Of what ) Foot Surgery Left Right Oophorectomy Breast augmentation Fracture: Orthopedic Surgery: Bypass graft Caesarean section Gallbladder surgery Spinal Surgery: Carpal Tunnel Release Hemorrhiodectomy Thyroidectomy Hernia Repair Tracheostomy Family History Mark all appropriate diagnosis as they pertain to your biological Mother and Father only: Mother Father Arthritis Cancer Diabetes Headaches Heart Kidney Liver Rheumatoid Osteoporosis Seizures stroke Disease problems problems arthritis I am adopted: I have no significant family medical history: Review of System: (Circle all that you currently have) General: Change in appetite Excessive sweating Low sex drive Chills Excessive thirst Malaise Difficulty Sleeping Fatigue Night Sweats Easy bruising Insomnia Tremors Musculoskeletal: Limitation of motion Muscle wasting Swelling, Joint Muscle cramps Muscle weakness Muscle spasms Stiffness 4
5 Neurological: Abnormal gait Involuntary movement Tingling Carpal tunnel syndrome Memory Loss Tremors Disorientation Numbness Weakness Dizziness Paralysis Fainting Seizure Gastrointestinal: Acid reflux Diarrhea Gallstones Belching Fecal incontinence Nausea Bloating Flatulence Vomiting Constipation Food intolerance Psychiatric: Anxiety Irritability Panic Episodes Depression Memory Changes Suicidal Thoughts Review of System: (Circle all that you currently have) HEENT: Blurred vision Eye pain nasal discharge Cataracts Facial pressure Nose bleeds Color blindness Glaucoma Ringing in the Ears Deafness Hoarseness Runny Nose Double vision Loss of smell Sinus problem Earache Metallic taste Toothache Excessive tearing Nasal congestion Respiratory: Cough Short of Breath Wheezing Exposure of TB Snoring Cardiac: Chest Pain Edema Fainting Lightheadedness PATIENT SIGNATURE: REVIEWED WITH PATIENT: 5
6 PREVIOUS TREATMENT What treatment(s) have you had for this problem so far? MEDICATION MANAGEMENT: o LIST MEDICATIONS FAILED PREVIOUS INJECTIONS OR SURGERY: PHYSICAL THERAPY: Please bring PT Visit Notes o WHERE AND HOW LONG WAS THE TREATMENT CHIROPRATIC TREATMENT o WHERE AND HOW LONG WAS THE TREATMENT What percent improvement have you had since onset (0-100%)? % PAIN SCALE: On a scale in which 0 is no pain and 10 is the worst pain you can imagine, please rate your pain: Today (0-10) Best (0-10) Worst (0-10) Usually (0-10) How long can you Sit: Stand: Walk: Drive: How much to you think you can currently lift? lbs. 6
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?
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
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Interventional Pain Medicine P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Gainesville Braselton Medical Park 1, Suite 300 Medical Plaza B, Suite 402 1315 Jesse Jewell Parkway 1404 River
Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)
Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C ADULT SPINE HISTORY For Office Use Only: HR: BP: / Name of Patient: Date: Date of Birth: Age: Height: ft in Weight: lbs Form
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
Florida Hospital Spine Center Patient Intake Form
Florida Hospital Spine Center Patient Intake Form Today s Date Last Name First Name Middle Street Address DOB (Address, City, State, Zip Code) First Contact # Please Circle: Home Cell Other Second Contact
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please