Please complete ALL 6 pages of the form in blue/black ink. Patient Acct # Provider # BMI # Height Weight
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- Georgiana Hodge
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1 Please complete ALL 6 pages of the form in blue/black ink. Patient Acct # Provider # BMI # Height Weight f-25-n ( ) ( ) 0 10
2 Spine Questionnaire (continued) OFFICE USE ONLY Patient Acct # Doctor # MD/NP/PA f-25-n F-25-N ( ) ( )
3 Spine Questionnaire (continued) OFFICE USE ONLY Patient Acct # Doctor # c Weight Loss/Gain c Fever c Arm Numbness c Stiffness c Severe Nighttime Pain c Difficulty Buttoning Buttons c Change in Handwriting Ability c Night Sweats c Recent Infections c Leg Numbness c Swelling c Difficulty Walking c Rashes c Changes in Appetite c Poor Sleep c Fatigue c Muscle Weakness c Joint Pain c Genital Numbness c Bowel Accidents/Incontinence c Mood Changes Agitation/Anxiety c Bladder Accidents/Incontinence c Bleeding/Bruising Problems c Blurred Vision c Dizziness c Recent Chest Pain c Shortness of Breath c Other (describe): c High Blood Pressure c Heart Disease c Liver Disease c Seizures/Epilepsy c Thyroid Disease c Lung Disease c Diabetes c Psychiatric Illness c Kidney Disease c Acid Reflux c Osteoporosis c Osteoarthritis c Rheumatoid Arthritis c Ulcers c High Cholesterol c c Cancer (please specify): c Other (please specify): c Lumbar Spine/Low Back c Kidney c Prostate c Cervical Spine/Neck c Bowel c Breast c Heart c Hernia c Extremities/Arms or Legs c Lung c Gallbladder c Hysterectomy c Appendectomy c C-section c c Other (please describe): c Penicillin; reaction c Sulfa; reaction c Iodine; reaction c Codeine; reaction c Other Medications; reaction c g c Cancer c Diabetes c Arthritis c Heart Disease c Stroke c Neck/Low Back Pain c High Blood Pressure c Other: Are You: c Single c Married c Widowed c Separated c Divorced Do You Live: c Alone c With Others Are You: c Employed c Retired c Disabled What Is(was) Your Occupation? Is Your Job: c Sedentary c Light c Medium c Heavy If Unemployed, How long have you not been working? Do You Smoke: c No c Yes, How Much Have You Ever Smoked: c No c Yes, Number of years When Did You Quit? Do You Drink Alcohol: c No c Yes, How much/week Do You Use Illegal Drugs: c No c Yes, How Much/Week Highest Level of Education Completed: c GED c High School c College c Graduate School c Other: f-25-n F-25-N ( ) ( ) page 3
4 Scoliosis and Spine Center of Maryland OFFICE USE ONLY Patient Acct # Doctor # Patient Name: Date: Neck Disability Index This questionnaire has been designed to give us information as to how your neck pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only the one box that applies to you. We realize you may consider that two or more statements in any one section relate to you, but please just mark the box that most closely describes your problem. Section 1: Pain Intensity o I have no pain at the moment o The pain is mild at the moment o The pain comes and goes and is moderate o The pain is moderate and does not vary much o The pain is severe but comes and goes o The pain is severe and does not vary much Section 2: Personal Care (Washing, Dressing, etc.) o I can look after myself normally without causing extra pain o I can look after myself normally but it causes extra pain o It is painful to look after myself and I am slow and careful o I need some help but can manage most of my personal care o I need help every day in most aspects of self care o I do not get dressed, I wash with difficulty and stay in bed Section 3: Lifting o I can lift heavy weights without extra pain o I can lift heavy weights, but it causes extra pain o Pain prevents me from lifting heavy weights off the floor, but I can if they are conveniently positioned, for example on the table o Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned o I can only lift very light weights o I cannot lift or carry anything at all Section 4: Reading o I can read as much as I want to with no pain in my neck o I can read as much as I want to with slight pain in my neck o I can read as much as I want with moderate pain in my neck o I cannot read as much as I want because of moderate pain in my neck o I cannot read as much as I want because of severe pain in my neck o I cannot read at all Section 5: Headaches o I have no headaches at all o I have slight headaches, which come infrequently o I have moderate headaches, which come infrequently o I have moderate headaches, which come frequently o I have severe headaches, which come frequently o I have headaches almost all the time Section 6: Concentration o I can concentrate fully when I want to with no difficulty o I can concentrate fully when I want to with slight difficulty o I have a fair degree of difficulty in concentrating when I want to o I have a lot of difficulty in concentrating when I want to o I have a great deal of difficulty in concentrating when I want to o I cannot concentrate at all Section 7: Work o I can do as much work as I want to o I can only do my usual work, but no more o I can do most of my usual work, but no more o I cannot do my usual work o I can hardly do any work at all o I can t do any work at all Section 8: Driving o I can drive my car without neck pain o I can drive my car as long as I want with slight pain in my neck o I can drive my car as long as I want with moderate pain in my neck o I can t drive my car as long as I want because of moderate pain in my neck o I can hardly drive at all because of severe pain in my neck o I can t drive my car at all Section 9: Sleeping o I have no trouble sleeping o My sleep is slightly disturbed (less than 1 hr sleepless) o My sleep is mildly disturbed (1-2 hrs sleepless) o My sleep is moderately disturbed (2-3 hrs sleepless) o My sleep is greatly disturbed (3-5 hrs sleepless) o My sleep is completely disturbed (5-7 hrs sleepless) Section 10: Recreation o I am able to engage in all recreation activities with no pain in my neck at all o I am able to engage in all recreation activities with some pain in my neck o I am able to engage in most, but not all recreational activities because of pain in my neck o I am able to engage in few of my usual recreational activities because of pain in my neck o I can hardly do any recreational activities because of pain in my neck o I can t do any recreation activities at all Score: This spine follow-up form has been reviewed by: MD/NP/PA Date: F-25-N f-25-n ( ) ( ) 4
5 Account Number: Scoliosis and Spine Center SF-36 Patient Name: This questionnaire asks for your views about your general health. This information will help keep track of how you are feeling and how well you are able to do your usual activities. For each of the following questions, please mark with an X in the one box that best describes your answer. Please do not skip any questions. 1. In general, would you say your health is: Excellent Very Good Good Fair Poor 2. Compared to one year ago, how would you rate your health in general now? Much better now than 1 year ago About the same as 1 year ago Much worse now than 1 year ago Somewhat better now than 1 year ago Somewhat worse now than 1 year ago 3. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Yes Yes No Limited a lot Limited a little Not limited at all a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports b. Moderate activities, such as moving a table, pushing A vacuum cleaner, bowling, or playing golf c. Lifting or carrying groceries d. Climbing several flights of stairs e. Climbing one flight of stairs f. Bending, kneeling, or stooping g. Walking more than one mile h. Walking several blocks i. Walking one block j. Bathing or dressing yourself 4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? Yes No a. Cut down the amount of time you spent on work or other activities b. Accomplished less than you would like c. Were limited in the kind of work or other activities d. Had difficulty performing the work or other activities (for example, it took extra effort) 5. During the past 4 weeks have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious?) Yes No a Cut down on the amount of time you spent on work or other activities b. Accomplished less than you would like c. Didn t do work or other activities as carefully as usual
6 Account Number: Scoliosis and Spine Center SF During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? Not at all Slightly Moderately Quite a bit Extremely 7. How much bodily pain have you had during the past 4 weeks? Very Mild Mild Moderate Severe 8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? Not at all A little bit Moderately Quite a bit Extremely 9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the answer that comes closest to the way you have been feeling: How much of the time during the past 4 weeks All of Most of A good bit Some of A little of of Of the time the time of the time the time the time the time a. Did you feel full of pep? b. Have you been very nervous? c. Have you felt so down in the dumps? d. Have you felt calm and peaceful? e. Did you have a lot of energy? f. Have you felt downhearted and blue? g. Did you feel worn out? h. Have you been happy? i. Do you feel tired? 10. During the past 4 weeks, how much of your time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.) All of the time Most of the time Some of the time A little of the time of the time 11. How true or false is each of the following statements for you? Definitely Mostly Don t Mostly Definitely True True Know False False a. I seem to get sick a little easier than other people b. I am as healthy as anybody I know c. I expect my health to get worse d. My health is excellent Patient Signature: Date:
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Good. Poor [ ] [ ] Yes, at all [ A ] Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [ ] [ ]
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COOK CHIROPRACTIC CLINIC 1715 S MAIN ST KANNAPOLIS NC FX:
COOK CHIROPRACTIC CLINIC 1715 S MAIN ST KANNAPOLIS NC 28081 704-938-7111 FX:704-932-4066 Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address Line
New Patient Questionnaire KNEE Adult Reconstruction & Joint Replacement
New Patient Questionnaire KNEE Adult Reconstruction & Joint Replacement Name: DOB: Date: Height: Weight: Age: Chief Complaint Laterality Left Right Both Please describe your symptoms: (Mark all that apply)
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
New Patient History Inventory
ffice Use Arrival: Checked In: Roomed: ***PLEASE USE BLACK INK*** New Patient History Inventory Patient Name: Date of Birth: Age: What brings you to the office, and when was the date it started? Did your
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 #
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
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.
Comparative study of health status in working men and women using Standard Form -36 questionnaire.
International Journal of Pharmaceutical Science Invention ISSN (Online): 2319 6718, ISSN (Print): 2319 670X Volume 2 Issue 3 March 2013 PP.30-35 Comparative study of health status in working men and women
Do not write in this box. Name: Appointment: Date: Appointment Time: Primary Care Provider: Phone: Fax: Referring Physician: Address:
3901 Rainbow Boulevard Do not write in this box Appointment: Date: Appointment Time: Birth date: Age: Gender: Male Female Primary Care Provider: Phone: Fax: Referring Physician: Address: Phone: Fax: CHIEF
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)
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
HD CLINIC MEDICAL HISTORY FORM
HD CLINIC MEDICAL HISTORY FORM Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the questions below as best as you can. If you need assistance, a caregiver/companion
Physician initials. Date: / / Birthdate: / / Age: Sex: F M
Arthritis and Rheumatology Clinical Center of Northern Virginia R RHEUMATOLOY PATIENT HISTORY FORM Date: / / NAME: Last First M. I. Birthdate: / / Age: Sex: F M Marital status: Never married Married Divorced
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
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
**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
PRIMARY COMPLAINT: Date when symptom first appeared Did it begin: Gradual Sudden Progressive over time
PATIENT HISTORY 1 Date of Birth Age Social Security # Last First Middle Initial Address City ST Zip Phone (H) (W) (C) Email May we send you our online newsletter? Yes No Your Occupation Employer Spouse
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.
Hospital Information
Hospital Information What should I do before coming to the hospital? Unless otherwise instructed, do not eat or drink anything later than 8 hours before your surgery. If you are having a procedure that
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip