NEW PATIENT QUESTIONNAIRE
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- Todd Newman
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1 NEW PATIENT QUESTIONNAIRE PATIENT NAME: PRIMARY DOCTOR: DATE: REFERRING DOCTOR: Please show the location of your pain by drawing on the figures below:
2 Pain History 1. WHERE IS YOUR PAIN LOCATED? 0 Low Back 0 Neck 0 Mid Back 0 Face 0 Head 0 Right Arm 0 Left Arm 0 Right Leg 0 Left Leg 2. WHERE DOES THE PAIN RADIATE? 0 Right Leg 0 Left Leg 0 Both Legs 0 Other 0 Right Arm 0 Left Arm 0 Right Leg 3. THE PAIN FIRST STARTED: DAYS AGO 0 WEEKS AGO 0 MONTHS AGO 0 YEARS AGO 0 OTHER: 4. HOW WOULD YOU DESCRIBE YOUR PAIN? 0 Aching 0 Throbbing 0 Sharp 0 Dull 0 Numb 0 Nagging 0 Shooting 0 Burning 0 Tingling 0 Stabbing 0 Other: 5. RATE YOUR PAIN AT ITS WORST IN THE LAST 24 HOURS NO PAIN 6. RATE YOUR PAIN AT ITS BEST IN THE LAST 24 HOURS NO PAIN 7. HOW SEVERE IS YOUR PAIN ON AVERAGE? NO PAIN 8. HOW MUCH DOES YOUR PAIN INTERFERE WITH YOUR ACTIVITIES WORST PAIN IMAGINABLE WORST PAIN IMAGINABLE WORST PAIN IMAGINABLE 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% N0 INTERFERENCE COMPLETELY INTERFERES 9. HOW MUCH DOES YOUR PAIN INTERFERE WITH YOUR SLEEP 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% N0 COMPLETELY INTERFERENCE INTERFERES 10. THE PAIN IS: 0 Constant 0 Intermittent 0 Worse in morning 0 Worse in afternoon 0 Worse in evening 0 Worse at night 11. WHAT MAKES THE PAIN WORSE? 0 Standing 0 Walking 0 Bending 0 Lifting 0 Sitting 0 Medications 0 Ice 0 Heat 0 Lying Down Other: 2
3 12. WHAT MAKES THE PAIN BETTER? 0 Standing 0 Walking 0 Bending 0 Lifting 0 Sitting 0 Medications 0 Ice 0 Heat 0 Lying Down Other: 13. IN ADDITION TO THE PAIN, DO YOU HAVE? 0 Numbness 0 Weakness 0 In the Right Leg 0 In the Left Leg 0 In Both Legs 0 In the Right Arm 0 In the Left Arm 0 In Both Arms 0 New Bladder 0 Incontinence 0 New Bowel 0 Incontinence 0 None of These 14. IS YOUR PAIN 0 Getting Better 0 Getting Worse 0 Staying About the Same 15. WHAT MEDICATIONS HAVE YOU TRIED FOR YOUR PAIN? (Check all that apply) Anti-Inflammatory: 0 Ibuprofen (Advil, Motrin) 0 Naproxen 0 Celebrex 0 Aspirin 0 Relafen 0 Meloxicam (Mobic) 0 Indomethicin Narcotic: 0 Morphine 0 Avinza 0 MSIR 0 MS Contin 0 Kadian 0 Dilaudid 0 Oxycodone 0 Oxycontin 0 Darvocet 0 Darvon 0 Hydrocodone 0 Vicodin 0 Lortab 0 Lorcet 0 Norco 0 Fentanyl 0 Duragesic 0 Actiq 0 Fentora 0 Codeine 0 Tramadol 0 Ultram 0 Stadol 0 Percocet 0 Percodan Antidepressants 0 Duloxetine (Cymbalta) 0 Fluoxetine (Prozac) 0 Escitalopram (Lexapro) 0 Venflaxine (Effexor) 0 Sertraline (Zoloft 0 Amitriptyline (Elavil) 0 Trazodone (Deseryl) 0 Nortriptyline (Pamelor) 0 Desipramine(Norpramine) 0 Buproprion (Wellbutrin) 0 Nefazodone (Serzone) 0 Citalopram (Celexa) 0 Paroxetine (Paxil) Anti-Seizure: 0 Gabapentin (Neurontin) 0 Pregabalin (Lyrica) 0 Zonisamide (Zonegram) 0 Carbamazepine (Tegretol) 0 Lamotrigine (Lamictal) 0 Oxycarbazepine (Trileptal) 0 Tiagabine (Gabatril) 0 Topiramate (Topamax) Muscle Relaxants/ Anti-Anxiety: 0 Baclofen (Lioresal) 0 Tizanidine (Zanaflex) 0 Methocarbamol (Robaxin) 0 Alprazolam (Xanax) 0 Metaxolone (Skelaxin) 0 Cyclobenzaprine (Flexeril) 0 Carisoprodol (Soma) 0 Diazepam (Valium) 0 Clonazepam (Klonopin) Sleeping Aids: 0 Zolpidem (Ambien) 0 Eszopiclone (Lunesta) 0 Amitriptyline 0 Temazepam (Elavil) (Restoril) 0 Zalepion (Sonata) 0 Trazodone (Deseryl) 0 Tylenol PM 3
4 Other Pain Meds: 0 Lidoderm Patch 0 Flector Patch 0 Topical Gel 0 Mirapex 14. WHAT TREATMENTS HAVE YOU HAD FOR YOUR PAIN? 0 Physical Therapy 0 Water Therapy 0 Traction 0 Exercise 0 Yoga 0 Psychology 0 Acupuncture 0 Chiropractic 0 Massage 0 TENS 0 Biofeedback 0 Hypnosis 0 Rolfing 0 Epidural Injections 0 Facet Injections 0 Trigger Point Injections 0 Nerve Blocks 0 Spinal Pump 0 Spinal Cord Stimulator Other: PAST MEDICAL HISTORY (Please fill in yes or no to all questions) CARDIOVASCULAR GASTROINTESTINAL Cardiac Arythmia 0 YES 0 NO Irritable Bowel Syndrome 0 YES 0 NO Heart Attack 0 YES 0 NO Peptic Ulcer Disease 0 YES 0 NO Coronary Artery Disease 0 YES 0 NO Indigestion/Acid Reflux 0 YES 0 NO Atrial Fibrillation 0 YES 0 NO Hiatus Hernia 0 YES 0 NO Mitral Valve Prolapse 0 YES 0 NO Hepatitis B 0 YES 0 NO Congestive Heart Failure 0 YES 0 NO Hepatitis C 0 YES 0 NO High Blood Pressure 0 YES 0 NO Ulcerative Colitis 0 YES 0 NO High Cholesterol 0 YES 0 NO DVT ( Blood Clot) 0 YES 0 NO OTHER Kidney Stones 0 YES 0 NO RESPIRATORY Kidney Failure 0 YES 0 NO Asthma 0 YES 0 NO Kidney Disease 0 YES 0 NO COPD Emphysema 0 YES 0 NO Hypothyroidism 0 YES 0 NO Sleep Apnea 0 YES 0 NO Lupus 0 YES 0 NO Cancer 0 YES 0 NO NEUROLOGY If so, what kind? 0 YES 0 NO TMJ 0 YES 0 NO Osteoporosis 0 YES 0 NO Seizures 0 YES 0 NO Fibromyalgia 0 YES 0 NO Trigeminal Neuralgia 0 YES 0 NO Arthritis-Rheumatoid 0 YES 0 NO Headaches - Migraines 0 YES 0 NO Osteoarthritis 0 YES 0 NO Headaches Tension 0 YES 0 NO RSD 0 YES 0 NO Headaches Cluster 0 YES 0 NO Anemia 0 YES 0 NO Post-Herpetic Neuralgia 0 YES 0 NO Diabetes (insulin) 0 YES 0 NO Multiple Sclerosis 0 YES 0 NO Diabetes (no insulin) 0 YES 0 NO Myasthenia Gravis 0 YES 0 NO Stroke 0 YES 0 NO OTHER SERIOUS MEDICAL PROBLEMS PSYCH WE SHOULD KNOW Anxiety/Depression 0 YES 0 NO ABOUT: Bipolar Disorder 0 YES 0 NO Schizophrenia 0 YES 0 NO Dementia 0 YES 0 NO SOCIAL HISTORY Do you drink alcohol? 0 Occasionally 0 Daily 0 Weekly Do you smoke? 0 <1 ppd 0 1 ppd 0 2 ppd 0 3 ppd Do you exercise? 0 Yes 0 No If yes, what do you do: Do you work? 0 Full-Time 0 Part-time 0 Homemaker 0 Retired 0 Unemployed due to Pain Occupation: Do you use illegal Drugs? 0 Yes 0 No 0 Used in the Past Type: 4
5 OTHER SYMPTOMS (Please indicate other symptoms you may have) CONSTITUTIONAL HEMATOLOGY Fever 0 Yes 0 No Abnormal Bruising 0 Yes 0 No Fatigue 0 Yes 0 No Abnormal Bleeding 0 Yes 0 No Insomnia 0 Yes 0 No Weight Loss 0 Yes 0 No NEUROLOGY Weight Gain 0 Yes 0 No Seizures 0 Yes 0 No Loss of Appetite 0 Yes 0 No Headache 0 Yes 0 No Memory Loss 0 Yes 0 No GI Numbness 0 Yes 0 No Blood in stool 0 Yes 0 No Where? Diarrhea 0 Yes 0 No Vomiting 0 Yes 0 No URINARY Constipation 0 Yes 0 No Urinary Retention 0 Yes 0 No Nausea 0 Yes 0 No Incontinence 0 Yes 0 No Difficulty Swallowing 0 Yes 0 No Abdominal Pain 0 Yes 0 No RESPIRATORY Heartburn 0 Yes 0 No Wheezing 0 Yes 0 No CARDIOVASCULAR MUSCULOSKELETAL Dizziness 0 Yes 0 No Joint Pain 0 Yes 0 No Chest Pain 0 Yes 0 No Joint Stiffness 0 Yes 0 No Palpitations 0 Yes 0 No Back Pain 0 Yes 0 No Leg Swelling 0 Yes 0 No Muscle Weakness 0 Yes 0 No Shortness of Breath 0 Yes 0 No PSYCH ENT Depression 0 Yes 0 No Cough 0 Yes 0 No Sleep Disturbances 0 Yes 0 No Suicidal Ideation 0 Yes 0 No OTHER CONCERNS: Anxiety 0 Yes 0 No CURRENT MEDICATIONS (Include dosage and # of tablets per day) 5
6 Have you had any surgeries? Are you taking any blood thinners, such as Coumadin or Plavix? 0 Yes 0 No If so, what: Do you have any allergies we should know about, such as to latex or iodine 0 Yes 0 No If so, what: Do you have any allergies to Medications? 0 Yes 0 No If so, what: What are your goals for your pain treatment? Are there any specific treatments you feel would help your pain? Medications: Physical Therapy: Exercise: Injections: Psychologist Referral: Surgical Referral: Platelet Rich Plasma or Other New Therapies Other Pain Therapies: Do you have a driver with you today? 0 Yes 0 No THIS IS THE END OF THE QUESTIONNAIRE. THANK YOU! 6
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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
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
NEW PATIENT INTAKE FORM
WILLIAM S. CRAWFORD, MD NEW PATIENT INTAKE FORM Patient Name: DOB: INSTRUCTIONS: Please complete the following questionnaire before you see the doctor. Answer each question in as much detail as possible.
Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
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
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. If you already completed this form in the last 3 months, please fill
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight:
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight: I Referring Doctor Complete Name of Referring Doctor Last Complete Address
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
Florida Orthopaedic Institute Urgent Care
Date: Florida Orthopaedic Institute Urgent Care Patient Questionnaire Initial Evaluation Patient Name: MR# (Office Use only): Family/Primary Doctor: Phone: Family/ Primary Doctor Address: Who referred
Pain Drawing. Name: Today s Date: How were you referred to the office: Visual Analog Scale
Pain Drawing Name: Today s Date: How were you referred to the office: Please be sure to fill this out as accurately as possible. This will become part of your permanent medical record and will be used
PAIN. TREATMENT TABLES Analgesics. NON-OPIOID ANALGESICS Generic Name Trade Names (Examples) Duration Initial Dose
NON-OPIOID SHORT-ACTING LONG-ACTING **** O PAIN TREATMENT TABLES Analgesics NON-OPIOID ANALGESICS Generic Name Trade Names (Examples) Duration Initial Dose Tramadol 50 mg Ultram Every 4 hours 1-2 tabs,
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Last Name First Name Middle Name MRN
Dr. Byers Dr. Su Dr. Sponzilli Lisa Elvin, NP Spine Center New Patient Form Last Name First Name Middle Name MRN This form is used to gather information so that my doctor can maximize the time used to