CENTURION PAIN MANAGEMENT
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- Ferdinand Hood
- 5 years ago
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Transcription
1 Today s date : (Fecha) First Name : (Nombre) Last Name : (Apellido) Age Date of Birth: Sex: M or F (Edad) (Fecha de nacimiento) (sexo) Street Address: City: State Zip: (Direccion) Home Phone: Cell phone: Work: (Telefono de casa) (Celular) (Telefono de trabajo) Referring Physician: Phone: (Doctor referente) (Telefono) Primary Care Physician: Phone: Pharmacy: 1
2 When did your pain start? Is it related to a Car Accident or Work Injury: Yes or No (Cuando empezó su dolor?) (Esta su dolor relacionado a accidente de auto o trabajo?) Si o No Which words describe the pain? (please circle): (Describa su dolor, por favor circule abajo) Throbbing (palpitante) Aching (dolor) Sharp (agudo) Dull (sordo) Shooting (punzante) Tingling (hormigueo) Burning (ardiente) Numbness (entumecimiento) Hot (caliente) Cold (frio) Continuous (continuo) Intermittent (intermitente) Where does it hurt: Please mark with an X where your pain is. (Donde le duele. Por favor marque con una X donde le duele). Does your pain travel? if yes, please draw an arrow above where the pain travels. Su dolor se mueve? por favor ponga una flecha en direccion donde el dolor se mueve. Your pain on average is: ( /out of 10) and when it is at its worst is ( /out of 10) (Cuanto es su dolor regular ( /de 10) y cuanto es cuando es peor ( /de 10) What activities makes the pain worse? (con que actividades empeora el dolor): Sitting (sentarse) Standing (estar de pie) Walking (caminar) Goingup/down stairs Bending (doblarse) Lying down (acostarse) Driving (conducir) Coughing/sneezing (toser/estornudar) Other What activities makes the pain better? (con que se mejora el dolor): Sitting (sentarse) Standing (estar de pie) Walking (caminar) Bending (doblarse) Lying down (acostarse) Driving (conducir) Coughing/sneezing (toser/estornudar) Other 2
3 Does the pain cause you sleep disturbance? (El dolor le causa problemas para dormir?) Does the pain is cause you depression? (Tiene usted depression?) Does the pain cause you anxiety? (Tiene usted ansiedad?) Does the pain cause you difficulty with : (El dolor le causa dificultad para): Eating Dressing Bathing Getting up from bed/chair Using the toilet Other activities Comer Vestirse Banarse Levantarse de la cama o silla Usar el bano. Otras actividades TREATMENT HISTORY: What treatment are you currently having now or have you had for your pain and did it help your pain (circle all that apply): (Que tratamiento esta recibiendo o ha recibido para su dolor y si le ayudo?) Now Past Does it help (ahora) (pasado) (le ayuda) Physical Therapy (Terapia fisica) Psychologist ( Psicologico) Chiropractic (Quiropractico) Acupuncture (acupuntura) What type of injections have you received for your pain recently, which body part? (Que tipo de inyecciones ha recibido para el dolor recientemente y donde?) Have you have any of the following test to evaluate your pain? (Se ha realizado alguno de los siguientes estudios para evaluar su dolor?) X rays (rayos X) MRI CT scan EMG Please list all your CURRENT medications, list your PAIN medication first: (Liste los medicamentos que esta tomando) Name of Drugs Nombre del medicamento How many times a day? Cuantas veces al dia? Prescribing doctor Doctor que prescribe 3
4 Circle all PAIN medications you have tried in the PAST FOR TREATMENT OF YOUR PAIN and circle the reason for stopping the medication (Circule los medicamentos de dolor que ha tomado en el pasado y circule porque razon dejo de usarlo) Neurontin (gabapetin): no specific reason Did not help Causing side effects Causing allergic reactions no razon especifica No me ayudo Effectos secundarios Reacciones alergicas Lyrica: No specific reason Did not help Causing side effects Causing allergic reactions Flexeril (Cyclobenzaprine): No specific reason Did not help Causing side effects Causing allergic reactions Zanaflex (Tizanidine): No specific reason Did not help Causing side effects Causing allergic reactions Skelaxin (Metaxalone): No specific reason Did not help Causing side effects Causing allergic reactions Tramadol: No specific reason Did not help Causing side effects Causing allergic reactions Tylenol with codeine: No specific reason Did not help Causing side effects Causing allergic reactions Morphine: No specific reason Did not help Causing side effects Causing allergic reactions Vicodin: No specific reason Did not help Causing side effects Causing allergic reactions Percocet: No specific reason Did not help Causing side effects Causing allergic reactions SURGICAL HISTORY: Please list all surgeries you have had (Liste las cirugías que ha tenido) Date (fecha) 4
5 MEDICAL HISTORY: PLEASE CHECK ALL YOUR MEDICAL CONDITIONS (por favor marque su condicion medica) High blood pressure ( Presion alta ) Frequent cramping (Calambres frequentes) Heart surgery (cirugia del Corazon) Heart stent (Stent cardiaco) Pace maker (marcapaso) Angina (Angina, dolor en el pecho) Cholesterol (Colesterol) Asthma (asma) Emphysema (enfisema) Diabetes(how many years) (Diabetico/a por cuanto tiempo?) Thyroid disease (Enfermedad de la tiroide) Fever or chills (fiebre o escalofrios) Fatigue (fatiga) Stroke (CVA), right or left side (derrame cerebral) lado derecho o izquierdo Seizure (convulsiones) Are you taking meds for it? Toma medicamentos Indigestion Heartburn (Acidez) GI bleed/ulcers (Sangrado gastrointestinal/ulceras) Nausea or vomiting (Nausea o vomito ) Constipation (Estreñimiento ) Hepatitis what type [ ] Hepatitis que tipo [ ] Enlarge Prostate (Agrandamiento de la prostata) Urinary Incontinence (incontinencia urinaria) Sexual dysfunction (Disfuncion sexual) Cancer (specify) (especifique ) Osteoporosis Visual problems (problemas visuales Sleep apnea (apnea del sueno) Other Otro 5
6 (SOCIAL HISTORY) (Historia social ): Do you smoke? Yes or NO How many cigarettes a day? (Usted fuma?) Si o No Cuantos cigarillos al dia? Do you drink alcohol EXCESSIVELY or have a problem with alcohol abuse? Yes or NO (Toma usted alcohol EXCESIVAMENTE) Si o No Have you used any illegal drug or controlled medication for NON MEDICAL reasons in the past? Ha usado alguna droga ilegal or medicamento controlado con proposito NO MEDICO en el pasado año? No yes No Si Does anyone in your family has a problem with controlled medication or illegal drug abuse? Yes No Alguna persona en su familia tiene un problema de abuso de medicamentos controlados o abuso de drogas? Si No Have you been sexually abused? Yes or No Ha sido abusado sexualmente? Si o No What is your current working status? Employed Un employed Retired Other (Cual es su estado de trabajo actual? Empleado Desempleado Retirado Otro Are you allergic to any medications (Es usted alergico a algun medicamento) Are you currently taking blood thinners such as? please circle (Esta usted tomando anticoagulantes?) Aspirine Coumadin Plavix Other Aspirina Cumadina Plavix Otro Family History: (Historia familiar): Please circle or list any serious medical conditions suffered by your immediate family? (Marque cualquier condición médica sufrida por su familia?) Father Cancer Heart condition Diabetes High blood pressure Other Padre Cancer Problema del corazon Diabetes Presion alta Otro Mother CancerHeart condition Diabetes High blood pressure Other Madre Cancer Problema del corazon Diabetes Presion alta Otro Siblings CancerHeart condition Diabetes High blood pressure Other Hermanos Cancer Problema del corazon Diabetes Presion alta Otro 6
7 7
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
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
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New Patient Intake Form. Please List All Current Medications. Please shade in the areas where you have pain
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Providence Medical Group-Hood River 1151 May St. Appointment date Hood River, OR fax Appointment time
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Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
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Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
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Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
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Subjective Medical History Information
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Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /
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* CC* PATIENT QUESTIONNAIRE
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight:
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Patient Information/ Información Del Paciente. Responsible Party (Mother/ Father) Personas Responsables (Madre/Padre)
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Do not write in this box. Name: Appointment: Date: Appointment Time: Primary Care Provider: Phone: Fax: Referring Physician: Address:
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WORKER S COMPENSATION PAIN QUESTIONNAIRE
Patient Name: Patient Date of Birth: Appointment Date: Please mark and/or notate the areas of your body which are affected by pain. RIGHT RIGHT LEFT LEFT RIGHT LEFT RIGHT RIGHT LEFT LEFT RIGHT LEFT For
CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:
JOSE G. VELIZ MD, INC. Diplomate of the American Board of Interventional Pain Management Diplomate of the American Board of Anesthesiology Diplomate of the American Board of Pain Medicine Fellow of Interventional
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT
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PATIENT INFORMATION FORM
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Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #
Patient Information: Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Email: Home # Cell # Work # Text Appointment Reminders: Yes No
RED-ROSE CHIROPRACTIC CLINIC, P.S NE 85 TH STREET KIRKLAND, WA (425) fax (425)
PATIENT INFORMATION DATE: BP: P: Patient Name: (First) (Last) (M.I.) Address: City, State: Zip Code: Home #: ( ) Cell #: ( ) Work #: ( ) Date of Birth: Age: Sex: M / F Email: Automatic Appointment Reminder
Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week
3 Washington Circle W, #207/208 Patient ame: Age: Chief Complaint: Please describe what you are being seen for today: What is your hand dominance (which hand do you write with)? Left Right Ambidextrous
HEALTH QUESTIONNAIRE
HEALTH QUESTIONNAIRE NAME AGE SEX: Male / Female DATE COMPLETED: OCCUPATION EMPLOYER HEIGHT WEIGHT BIRTHDATE DOMINANT HAND: Left / Right NAME OF YOUR PRIMARY CARE PHYSICIAN (INTERNIST OR PEDIATRICIAN):
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:
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
**PLEASE NOTE OUR NEW ADDRESS** The Spine Center 159 Wells Ave, Newton, MA Ph: Fax:
Helpful Telephone Numbers Pre-Registration 855-890-9241 Hospital Billing (NWH) 617-726-3884 Physician/Provider Billing (MGPO) 617-726-3884 Web Address nwh.org Pre-Registration Please call up to 7 days
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
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
Patient# WELCOME Today s Date / / Please fill out this form as completely as possible. Please print. PERSONAL INFORMATION Name What you prefer to be called Age Date of Birth / / Sex SS# E-Mail Home Address
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. Thank you for your cooperation. Patient
V. Singh, MD C. Piryani, MD K. Liao, MD J. Birgiolas, MD R. Chovatiya, MD PAIN QUESTIONNAIRE. Name: Date of birth: Age:
V. Singh, MD C. Piryani, MD K. Liao, MD J. Birgiolas, MD R. Chovatiya, MD PAIN QUESTIONNAIRE Date: Name: Date of birth: Age: Who referred you to this practice? (newspaper, TV, doctor, friend etc..) Who
IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED
Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
Thank you for visiting TDFK. We want your visit to be pleasant and comfortable. Please help us by completing this form.
(469) 206 7038 Fax: (469) 206-7256 Medical Alert for Office Use MINOR Thank you for visiting TDFK. We want your visit to be pleasant and comfortable. Please help us by completing this form. Patient Information
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?