REFERRED BY PAINFUL SIDE: RIGHT, LEFT, CENTRAL, RIGHT MORE, LEFT MORE, EQUAL ON BOTH SIDES, OTHERS DAILY PAIN: HRS MIN TIMES DAYS, WEEK, MONTH
|
|
|
- Leonard Garrett
- 5 years ago
- Views:
Transcription
1 NAME ADDRESS PHONE AGE DOB / / HT WT RACE MALE FEMALE SSN DATE OF ACCIDENT: / / REFERRED BY DATE OF VISIT CIRCLE APPROPRIATE ANSWERS OR EXPLAIN: 1. TYPE OF INJURY AUTO WORK OTHER PLEASE GIVE DETAILED EXPLANATION OF INJURY OR ACCIDENT. WAS IT A TWIST, LIFTING, OR A FALL? HOW FAR DID YOU FALL? GIVE HISTORY OF HOW THE PAIN STARTED EVEN IF NOT RELATED TO TRAUMA WHAT PART OF YOUR BODY WAS HURT? DID YOU LAND ON YOUR HANDS? (AUTO ONLY) SEATBELT ON? YES NO TYPE OF COLLISSION: FRONTEND REAR END BROADSIDE DRIVER PASSENGER HANDS ON STEERING WHEELS? YES NO HANDS HIT THE DASH BOARD? YES NO WHAT DID YOU STRIKE WITHIN THE CAR? WHAT PART OF THE BODY? ANY FRACTURES, LACERATIONS 2. (EXPLAIN) RECENT HISTORY A. DATE OF ONSET GRADUAL SUDDEN B. USE PAIN DIAGRAM ALSO (SEE PAGE 6) PAIN: NECK. MID BACK, LOW BACK, EXTREMITIES, WHAT JOINTS R L PAIN DESCRIPTION: SHARP, STABBING, SHOOTING, BURNING, ACHING, OR PAINFUL SIDE: RIGHT, LEFT, CENTRAL, RIGHT MORE, LEFT MORE, EQUAL ON BOTH SIDES, OTHERS DAILY PAIN: HRS MIN TIMES DAYS, WEEK, MONTH 3. NUMBNESS ARM. FOREARM. WRIST, HAND (PALM, BACK) FINGERS (THUMB, INDEX, M,D, RING, LITTLE) WHAT OTHER JOINTS R L THIGH. LEG, FOOT (TOP SOLE), TOES (BIG, 2, 3. 4, LITTLE) JOINTS R L
2 4. WEAKNESS: EXTREMITIES (ANYSTIFFNESS, CRAMPS. KNEES BUCKLING, FALLING) DROPPING OBJECTS FROM HANDS? YES NO (RIGHT. LEFT, BOTH; FREQUENT, OCCASIONAL). 5. DID YOU GO TO THE EMERGENCY ROOM? YES NO WHEN WHAT TESTS DID THEY PERFORM? WHAT TREATMENT DID YOU RECEIVE? 6. HAVE SYMPTOMS GOTTEN WORSE IN THE PAST: 1, 3, 6, 8, 12 MONTHS OR MORE? YES NO 7. WHICH SYMPTOMS BOTHER YOU THE MOST? PAIN. WEAKNESS. NUMBNESS? 8. WHICH AREA BOTHERS YOU THE MOST? NECK, MID-BACK, LOW-BACK, ARM, FOREARM, WRIST, FINGERS 9. HOW LONG HAVE YOU BEEN DISABLED BY PAIN? 10. DO YOU OCCASIONALLY NEED TO STOP ACTIVITIES DUE TO PAIN? YES NO IF YES, WHAT ACTIVITIES 11. HOW LONG CAN YOU SIT? STAND? WALK? (HRS OR MINUTES). 12. DO YOU HAVE TO USE CANES, CRUTCHES, WHEELCHAIR, RAILING TO CLIMB STAIRS? YES NO IFYES, WHICH DO YOU HAVE TO USE? 13. DO YOU EXPERIENCE ANY OF THE FOLLOWING SYMPTOMS DUE TO THE INJURY? HEADACHES DIZZINESS MEMORY LOSS CONCENTRATION DEFICITS NAUSEA VOMITING BLADDER DISTURBANCE WEAKNESS NUMBNESS BOWEL URGENCY/ACCIDENTS FATIGUE ANXIETY BLADDER URGENCY/ACCIDENTS DEPRESSION SWELLING DIFFICULTY WALKING IRRITABILITY HAIR LOSS SKIN COLOR CHANGES WEIGHT GAIN/LOSS LBS COLDNESS WARMTH 14. PLEASE RATE YOUR PAIN: (NO PAIN) (EXTREME PAIN) PAIN LEVEL TODAY AVERAGE DAY GOOD DAY BAD DAY 15. WHAT MAKES YOUR PAIN BETTER? (PLEASE CHECK ALL THAT APPLY) LYING DOWN WALKING SITTING STANDING MEDICATION SLEEP HEAT MASSAGE EXERCISE STRETCHING TRACTION TENS CORSET BIOFEEDBACK COMPRESSION OTHER? etoims history form Page 2 of 7
3 16. WHAT MAKES YOUR PAIN WORSE? STANDING SITTING BENDING TENSION LYINGDOWN LIFTING WEATHER DRIVING SEXUAL ACTIVITY WALKING WALKING UP STAIRS WALKING DOWN STAIRS REACHING OVERHEAD OTHER? 17. DO YOU HAVE SEVERE PAIN AT NIGHT? YES NO 18. DOES PAIN WAKE YOU FROM SLEEP? YES NO HOW MANY TIMES? WHAT POSITION, IF ANY, RELIEVES THE PAIN? DO YOU-HAVE DIFFICULTY FALLING ASLEEP AT NIGHT? YES NO DO YOU WAKE UP UNUSUALLY EARLY IN THE MORNING? YES NO HOW LONG CAN YOU SLEEP? WITH MEDICINES: (HRS) WITHOUT MEDICINES: (HRS) 19. PREVIOUS TREATMENT (CHECK ALL THAT APPLY) MODALITY TEMPORARY RELIEF LASTING PHYSICAL THERAPY ULTRASOUND HOTPACKS TRACTION YES NO HRS DAYS YES NO HRS DAYS SOFT TISSUE RELEASE YES NO HRS DAYS YES NO HRS DAYS ELECTRICAL STIMULATION YES NO HRS DAYS YES NO HRS DAYS THERAPEUTIC EXERC SE YES NO HRS DAYS YES NO HRS DAYS TENS YES NO HRS DAYS YES NO HRS DAYS BIOFEEDBACK YES NO HRS DAYS YES NO HRS DAYS CHIROPRACTOR YES NO HRS DAYS YES NO HRS DAYS PSYCHOLOGICAL SUPPORT YES NO HRS DAYS YES NO HRS DAYS BRACE SPLINT/CERVICAL COLLAR YES NO HRS DAYS YES NO HRS DAYS WORK HARDENING YES NO HRS DAYS YES NO HRS DAYS INJECTIONS (HOW MANY TIMES? WHICH ONE?) TRIGGER POINT FACET BLOCK EPIDURAL YES NO HRS DAYS YES NO HRS DAYS NERVE BLOCK SYMPATHETIC BLOCK YES NO HRS DAYS YES NO HRS DAYS ACUPUNCTURE YES NO HRS DAYS YES NO HRS DAYS IMPLANTS WHEN? WHERE? YES NO HRS DAYS YES NO HRS DAYS HAVE YOU BEEN SEEN AT A PAIN CLINIC? NO YES WHEN? WHERE? LIST NAMES OF PSYCHOLOGIST OR PSYCHIATRIST: 20. LIST OTHER TREATING PHYSICIANS, REHAB NURSES, THERAPISTS,VOCATIONAL COUNSELORS AND THEIR RECOMMENDED TREATMENTS etoims history form Page 3 of 7
4 21. CHECK ALL DIAGNOSTIC TESTS THAT YOU HAVE HAD? (PLEASE INDICATE WHERE THESE TESTS WERE TAKEN SO THAT WE CAN OBTAIN RESULTS) PLAIN X-RAYS CAT SCAN MRI SCAN EMG/NCV MYELOGRAM OTHER PAST MEDICAL HISTORY: 22. PLEASE LIST ANY INJURIES YOU HAVE HAD SINCE THE ACCIDENT YOU ARE HERE FOR TODAY: PLEASE LIST ANY PREVIOUS INJURIES (FALLS, AUTO ACCIDENT, WORK, OTHERS (DESCRIBE WHERE AND HOW INJURIES OCCURRED)? LOW BACK PAIN IN THE PAST? YES NO LEG PAIN? YES NO RIGHT LEFT BOTH HOW LONG DID PAIN LAST RELATED TO THE ABOVE PAST INJURIES WAS RESOLUTION OF PAIN COMPLETE YES NO OR INCOMPLETE 23. CHECK ANY PREVIOUS MEDICAL PROBLEMS: HEART DISEASE LUNG DISEASE KIDNEY DISEASE INTESTINAL DISEASE THYROID DIABETES HIGH BLOOD PRESSURE CANCER STROKE SEIZURE BLOOD CLOTS OSTEOARTHRITIS RADICULOPATHY DISC DISEASE CARPAL TUNNEL AMPUTATIONS NERVE INJURIES HEPATITIS BLEEDING DISORDERS INFECTIOUS DISEASES LIST ANY PREVIOUS SURGERIES 24, LIST ALL CURRENT MEDICATIONS: NAME DOSE (MGM) TIMES/DAY NAME DOSE (MGM) TIMES/DAY etoims history form Page 4 of 7
5 25. ARE YOU CURRENTLYWORKING? YES NO FULL DUTY LIGHT DUTY HOW LONG HAVE YOU BEEN OUT OF WORK? HAVE YOU TRIED TO RETURN TO WORK? YES NO WHEN? HOW LONG DID YOU WORK WHEN YOU RETURNED? WHY DID YOU STOP? TYPE OF JOB: HOW LONG? REASON FOR LEAVING NUMBER OF HOURS OCCUPATION (JOB TITLE) JOB DESCRIPTION (WORK DUTIES) EMPLOYER NUMBER OF HOURS: SITTING STANDING BENDING OVERHEAD WORK CLIMBING REPETITIVE UPPER EXTREMITY COMPUTER LIFTING 26. SOCIAL AND FAMILY HISTORY: MARITAL STATUS: MARRIED SINGLE SEPARATED DIVORCED WIDOWED YOUR SPOUSE HEALTHY? YES NO VERBAL OR SEXUAL ABUSE NUMBER OF CHILDREN AGES IS THERE A HISTORY OF VERBAL OR SEXUAL ABUSE? WHAT IS YOUR EDUCATIONAL LEVEL? HAVE YOU EVER SMOKED? YES NO AGE STARTED AGE STOPPED CUP OF COFFEE TEA SODA PER DAY RECREATIONAL DRUGS? YES NO HAVE YOU EVER OR DO YOU NOW DRINK ALCOHOL? YES NO DO YOU HAVE ANY FAMILY MEMBERS WHO DRANK EXCESSIVELY? YES NO ANY FAMILY MEMBERS WITH ARTHRITIS, NECK OR BACK SURGERIES? YES NO WHO 27. STRESSES: RELATIONSHIPS: FAMILY, FRIENDS, JOB, HOME, ETC. (PLEASE EXPLAIN): 28. PLEASE DESCRIBE YOUR DAILY ROUTINE: 29. DESCRIBE YOUR REGULAR EXERCISE ROUTINE AND FREQUENCY (ie. WALKING, STRETCHING, OTHERS) DO YOU LIKE TO EXERCISE? YES NO, IF NO, WHY? DO YOU HAVE TIME TO EXERCISE? etoims history form Page 5 of 7
6 30. REHABILITATION IS A GOAL ORIENTATED PROCESS. IT IS IMPORTANT TO SET REASONABLE GOALS AND EXPECTATIONS. PLEASE LIST YOURS IN THE SPACE PROVIDED BELOW. GOALS: SHORT-TERM (NEXT 3-6 MONTHS) GOALS: LONG-TERM( 6 MONTHS OR MORE) PAIN DIAGRAM: USING THE PAIN DESCRIPTION, PLEASE MARK THE AREAS OF YOUR PAIN. PLEASE NUMBER EACH PAINFUL AREA IN ORDER OF THE MOST TROUBLESOME, I.E., 1-10 ON THE DIAGRAM. R LEFT RIGHT RIGHT LEFT LEFT RIGHT etoims history form Page 6 of 7
7 PAIN DISABILITY INDEX Patient's name (please print) date Rating scales below measure the impact of chronic pain in your everyday life. We want to know how much the pain is preventing you from doing your normal activities. For each of the 7 categories of life activity listed, circle the one number that best reflects the level of disability you typically experience. A score of 0 means no disability at all. A score of 10 means that all the activities which you normally do have been disrupted or prevented by your pain. The ratings should reflect the overall impact of pain in your life, not just when the pain is at its worst. Make a listing for every category. If you think a category does not apply to you, circle 0. Family/home responsibilities: This category refers to activities related to the home or family. It includes chores and duties performed around the house (eg., yardwork) and errands or favors for other family members (eg., driving the children to school). Recreation: This category includes hobbies, sports and other leisure time activities. Social activity: This category includes parties, theater, concerts, dining out, and other social activities that are attended with family and friends. Occupation: This category refers to activities that are directly related to one s job. This includes non-paying jobs as well, such as that of a homemaker volunteer. Sexual behavior: This category refers to the frequency and quality of one s sex life. Self-care: This category includes personal maintenance and independent activities (example taking a shower, driving, getting dressed) Life-support activity: This category refers to basic life-supporting behaviors such as eating, sleeping and breathing. etoims history form Page 7 of 7
Medical History Questionnaire
Date Medical History Questionnaire Name DOB Reason for visit When did symptoms first appear Is the condition getting worse? Please rate your pain 0 1 2 3 4 5 6 7 8 9 10 No Pain Extreme Pain Please circle
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM Last Name: First Name: Middle: Home Phone: Other Contact: Other Contact: DOB: Age: Sex: Name of Referring Physician: Phone: Fax: Address: City: State: Zip: Name
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
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire Name: MR#:_ Date: Date of Injury: Referred By: Age: Date of Birth: Handed: R L Ambidextrous Male Female **** Mark
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
Baylor Physical Medicine and Rehabilitation NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny Dear Patient: Please complete this questionnaire before you come for your appointment. Be sure to call us as soon
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
* 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
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.
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
Subjective Medical History Information
Page 1 of 8 Date: Patient Account #: Patient Name: Insurance: Date of Birth: History of current condition 1. Which of the following best describes how your injurt occurred? (if your injury is post-surgical
HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
1 UT Health Austin Comprehensive Pain Management New Patient Questionnaire Thank you for scheduling a visit with the Comprehensive Pain Management Care Team. The responses you provide to these questions
ASSIGNMENT OF BENEFITS
ASSIGNMENT OF BENEFITS PATIENT NAME: First Middle Last PHONE NUMBER: Home: Work: HOME ADDRESS: City ZIP AGE: DOB: SSN: Status EMAIL ADDRESS: PATIENT EMPLOYER: How long? Occupation SPOUSE S EMPLOYER: Spouse
INITIAL PAIN EVALUTION QUESTIONNAIRE
INITIAL PAIN EVALUTION QUESTIONNAIRE We are interested in understanding more about your pain. Please help us by filling out this questionnaire. Please bring the completed questionnaire with you for your
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
PATIENT HEALTH HISTORY
Southern Oregon Physical Therapy Associates, Inc. 924 S. Riverside Ave. Medford OR 97501 541.773.7678 Fax 541.773.5517 Email: sopta@integra.net website: southernoregonphysicaltherapy.com Health History-1
Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D. PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC Name: Age: Sex: Male Female Occupation: Job description: Date: PLEASE ANSWER THE FOLLOWING QUESTIONS: Major
LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
Whom may we thank for referring you to this office Today s Date: PATIENT DEMOGRAPHICS? HRN: Name: Birth Date: Age: Male Female Address: City: State: Zip: E mail Address: Home Phone: Mobile Phone: Marital
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?
Back and Neck Pain Questionnaire
www.orthonc.com Back and Neck Pain Questionnaire Please print legibly in black ink. Answer only questions applicable to your condition. Leave other spaces blank. Date you are filling out this form: PERSONAL
PAIN MANAGEMENT IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.
PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and REPORTS of any X- rays, MRI or Cat scans. Patient s name:
The UW Pain Treatment and Research Center takes a holistic approach to your pain care.
Pain Treatment and Research Center 5249 East Terrace Drive Madison, WI 53718 Phone: (608) 263-9550 Dear Patient: The UW Pain Treatment and Research Center takes a holistic approach to your pain care. You
Initial Pain Management Patient Questionnaire
Appt. Date: Appt. Time: Boston Out-Patient Surgical Suites North Tel Fax: 781-407-5892 Initial Pain Management Patient Questionnaire Dear New Pain Management Patient, Welcome to the New England Pain Management
Name Date Date of Birth Last Name First Name Middle Initial. Employment Information
Zindt Chiropractic Center 3819 S M St Workmen s Compensation Tacoma, WA 98418 Information Name Date Date of Birth Last Name First Name Middle Initial Employment Information Employer s business name (at
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
MICHIGAN INTERVENTIONAL PAIN ASSOCIATES
MICHIGAN INTERVENTIONAL PAIN ASSOCIATES Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and REPORTS of any X- rays, MRI or
BACK AND LEG PAIN ASSESSMENT (Prior Surgery)
ANSWER EVERY QUESTION! SPINE SURGERY LTD. (IMPORTANT PATIENT INFORMATION FORM) BACK AND LEG PAIN ASSESSMENT (Prior Surgery) 1. NAME: DATE TODAY: 2. AGE: SEX: 3. PRESENTLY EMPLOYED? NO YES, How long there?
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone E-Mail Address
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
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.
WELCOME to the Florence Chiropractic and Wellness Center.
WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,
Who may we thank for referring you?
NEW PRACTICE MEMBER APPLICATION Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
SPARROW FAMILY CHIROPRACTIC
Whom may we thank for referring you to this office? SPARROW FAMILY CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS PM#: Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail Address:
New Practice Member Application
New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
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:
9834 Genesee, Suite 223B La Jolla, CA Phone Fax
PATIENT HEALTH QUESTIONNAIRE (Page 1) 9834 Genesee, Suite 223B La Jolla, CA 92037 Phone 858-277-7123 Fax 858-277-3470 ***Please fill out completely. Failure to do so may delay payment of your claim. Indicate
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider
New Practice Member Application
T 1 2 3 Date / / New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Cellular Provider Email Address Occupation Employer s Name Single / Married
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
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
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
Neurosurgery Clinic. I, hereby acknowledge, that I am not pregnant and understand the risks of having ionizing radiation. Date. Signature.
Name Chart # Neurosurgery Clinic I, hereby acknowledge, that I am not pregnant and understand the risks of having ionizing radiation. Date Signature X-ray Tech PATIENT INFORMATION FORM Name LAST FIRST
Chayapathy Jollu, MD Board Certified in Physical Medicine and Rehabilitation Patient Initial Pain Questionnaire
Patient Initial Pain Questionnaire Date: Last Name: First Name: Middle Name: Age: Gender: M F Right handed Left handed Referring Physician: Primary Care Physician: Address: Address: Phone: Phone: Fax:
Puritz Chiropractic Center Patient Health Questionnaire
PERSONAL INFORMATION Puritz Chiropractic Center Today's Date: File #: First Name: Middle Initial: Last Name: Preferred First Name / Nickname: Social Security #: - - Are you: right handed left handed ambidextrous
NECK PAIN QUESTIONNAIRE
NECK PAIN QUESTIONNAIRE This questionnaire is designed by your doctor to answer specific questions. Please answer each question as completely as possible. Name: Date: 1. How long have you had neck pain?
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):
APPLICATION FOR CARE AT CORE CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT CORE CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail
reasons for visit factors of complaint Date: Work comp injury Automobile accident Other injury
Date: LAST NAME FIRST NAME DATE OF BIRTH CURRENT AGE PRIMARY CARE PHYSICIAN PHONE NUMBER REFERRING PHYSICIAN PHONE NUMBER reasons for visit Work comp injury Automobile accident Other injury PRIMARY REASON
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit)
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit) Last name: First Name: Title: Mr. Mrs. Dr. Appt Date: Refer by: (Please provide name
APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: o Male o Female Address: City: State:
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
(Must be completed with blue ink pen) Last Name First Name Date / / Address City Zip. Home Phone Cell Phone. Social Security# Driver s License # State
(Must be completed with blue ink pen) (MR #: ) Last Name First Name Date / / Address City Zip Home Phone Cell Phone Email Birthday / / Sex: M F Social Security# Driver s License # State Occupation Employer
Cascadia Chiropractic Centre
Name: Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: Date of Birth: Your age: Care Card #: Address: City/Prov: Postal Code: Phone: Cell: Work Phone: E-mail Address: Marital
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
AUERBACH CHIROPRACTIC
AUERBACH CHIROPRACTIC ARTS AND SCIENCE Dr. Gary Auerbach 2730 N. Pantano Road Tucson, AZ 85715 Phone: 520-721-7177 Welcome to the office of Auerbach Chiropractic Arts and Science. In order to better serve
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
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
Numbness: o o o o o. Grade your overall pain. Pain Rating Scale Mosby. Worst Possible Pain. No Pain HURTS LITTLE MORE HURTS EVEN MORE
Patient Name: Original Referring Physician: Current PCP: PAIN DIAGRAM Is your condition the result of a: Work injury? YES NO Auto accident? YES NO Date of Injury: / / Please mark the areas of discomfort
BACK AND NECK PAIN QUESTIONNAIRE
Neurological Surgery and Spine Surgery, S.C. 1 Westbrook Corporate Center, Suite 800 Westchester, Illinois 60154 BACK AND NECK PAIN QUESTIONNAIRE Please PRINT all information CLEARLY and answer all questions
634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
eas 634 N. STATE STREET, WESTERVILLE OH, 43082 (614) 901-WELL www.abilitychiro.com Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: ( ) Cell Phone
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
NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE
NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE Today s : Patient Name: DOB: Race White/Caucasian Black/African American Asian Native American Alaskan Native Native Hawaiian Pacific Islander Other: Preferred Language:
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:
Re-Exam Questionnaire
Re-Exam Questionnaire Patient Name: Date: The following hi-lighted symptoms are what brought you into our office originally. DIRECTIONS: Please rate ALL hi-lighted symptoms: S = same; B = better; W = worse
PLEASE BRING COMPLETED PACKET TO APPOINTMENT ALONG WITH YOUR FILMS
PLEASE BRING COMPLETED PACKET TO APPOINTMENT ALONG WITH YOUR FILMS Advanced Spine Associates, P.A. NEW PATIENT MEDICAL HISTORY QUESTIONNAIRE Name Address City State Zip Age Date of Birth Sex M F Phone
APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male
FOR SECURITY REASONS, WE DO NOT ALLOW OCCUPIED VEHICLES IN OUR PARKING LOT.
Pain & Wellness of Centers of Georgia FOR SECURITY REASONS, WE DO NOT ALLOW OCCUPIED VEHICLES IN OUR PARKING LOT. I understand that if I receive a ride here, the people that accompany me MAY NOT wait in
PATIENT INJURY/MEDICAL HISTORY FORM
PATIENT INJURY/MEDICAL HISTORY FORM Name Date Date of Loss/Onset (Accident): Claim Number: _ Describe Accident: Specifics of Accident (Mark each that applies to the accident): Job or Work Related injury
Spine New Patient Questionnaire Rev
Spine New Patient Questionnaire Rev 10.13.10 Name: Male Female Temp: Height: Weight: Date of Visit: Date of Birth: Age Today: *Please note this is a multi-part questionnaire. When you are done, please
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
New Patient Pain History Form
New Patient Pain History Form Name: Date of Birth: / / Today s Date: / / Date the Pain Began: / / Reason for visit: Describe what caused the pain (accident, injury, etc.): Pain 1. Pain/Symptom Description
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
CONSULTATION QUESTIONNAIRE 1. What is your major symptom? 2. What does this prevent you from doing or enjoying? 3. If this is a recurrence, when was the first time you noticed this problem? How did it
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
NEW SPINE PATIENT QUESTIONNAIRE
NEW SPINE PATIENT QUESTIONNAIRE Patient Name (please print) Date Age Birthdate Gender: Male Female Primary Care Doctor Phone# Referring Doctor Phone# We routinely send a copy of all clinic notes to your
NON-INJURY QUESTIONNAIRE
Patient Name: Appointment Date: Appointment with: Dr. Jeffrey A. Kozak NON-INJURY QUESTIONNAIRE Why did you make an appointment to see the doctor? Evaluation Surgical Opinion Reassurance Other Specify:
New Patient Information
(Please Print) New Patient Information Name Address City/State/Zip Cell: Home: email: Social Security # Birthdate Age Male Female Occupation Employed by Wk ph. # Address City/State/Zip Number of Children
Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No
PATIENT ENTRANCE FORM Date Circle: Male Female Name Birth Date (dd/mm/yy) Age Address Apt # City Province Postal Code Home # Cell # Work # E-MAIL Occupation Employer Name of Emergency Contact 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
Welcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)
Patient s Name: Date: What is the reason for your visit today? Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone #
Temecula Pain Management Group, Inc
25495 Medical Center Dr. Murrieta, CA 92562 Tel. (951) 506-9536 Temecula Pain Management Group, Inc J. Druet M.D. S. Uraine M.D. K J. K. Ehlers PA-C H. Brickle PA-C NEW PATIENT VISIT Name Date of Visit:
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac. Personal History: Name: Address: City: Province: Postal Code: Birth date: day /month /year Age: Sex: M F Home Phone: Business Phone: Cell Phone: E-mail: Health
APPLICATION FOR CARE
3023 Eastland Blvd. Suite 101 Clearwater, FL 33761 Ph: 727-797-9900 Fax: 727-797-7695 APPLICATION FOR CARE Date: Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Email Address: Birth
Premier Orthopedic Spine Center
Premier Orthopedic Spine Center Atrium Medical Center Professional Buliding 200 Medical Center Dr., Ste. 375 Middletown, Ohio 45005 Neck Questionnaire Patient Date Family Physician The onset of my neck
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.
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?
PAIN QUESTIONNAIRE. Patient Name: Patient Date of Birth: Appointment Date:
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
Please fill out this form as completely as possible. This information will determine how we treat your pain problem.
Name Date of birth Age Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your
FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE
FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE Please circle answers to the questions that pertain to your problem. You may select more than one answer per question. This information will
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:
COMPREHENSIVE HEALTH & WELLNESS PROFILE
Patient Name DOB COMPREHENSIVE HEALTH & WELLNESS PROFILE The human body is designed to be healthy. Throughout life, events occur which damage your natural health expression. As a full spectrum Chiropractic
PATIENT HISTORY FORM
BodyCheck Prevention & Health Physical Therapy Centre PATIENT HISTORY FORM Please assist us by answering the following questions as completely and accurately as possible. Your answers will assist us by
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
3. How Long Has This Been An Issue?
NEW PATIENT INTAKE FORM Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX 76054 Name: Occupation: DOB: Age: Sex: Male Female Employer: Marital Status: Single Married Other Name/Age of Kids: Phone:
Patient Re-Examination Form
Harrisburg Family Chiropractic 220 S. Cliff Ave. Ste 106 Harrisburg SD 57032 (605) 767-7463 Name: Date: / / Patient Re-Examination Form Please fill out the information that has changed since your last
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Phone ( ) Age Birth Date Sex S.S.N. Employer Address Did you report this to YOUR Car Insurance? Yes No (Circle One) Your Car Insurance Co. is Claim # Claims Adjuster