Welcome to Lakernick Brain Center, Inc.
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- Cornelius Casey
- 5 years ago
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1 Welcome to Lakernick Brain Center, Inc. It is our pleasure to welcome you to Lakernick Brain Center, Inc. The examination and treatments available at are based on functional neurology, a discipline that builds on clinical neuroscience and uses various strategies to help improve or re-establish optimal neurological processes. For many individuals who have dealt with neurological or cognitive impairments, functional Neurologists can provide carefully determined, cautious and safe care that holds the prospect of potentially improving neurological function. These interventions can include various sources of input through visual, physical, and other neurologic channels. Therapeutic goals are determined by a thorough examination, assessment, review of records and consultation with the patient and additional specialists as required. Our doctors training includes an additional 4 years of clinical education after the Doctor of Chiropractic Degree. Many of our patients have been through years of other types of care and recovery, and have struggled to live within the limits imposed on them by their injuries. It is our hope that we can help you improve on those limitations; however, we must stress that we cannot make any promise of cure or improvement. After a careful intake process and examination, our Doctors will discuss treatment options with you and, if there is a reasonable expectation of some degree of clinical improvement, offer you the option of continuing under care. That care may or may not result in some degree of improvement. Any improvement may or may not be continuous, intermittent, or permanent. The human body is a wonderful, marvelous creation; it is capable of being self organizing, selfdeveloping, and self-healing. There are lien constraints on what our bodies are capable of doing, however, and it is impossible to predict how responsive individuals may be to functional neurological applications. Every person is unique. That uniqueness is an important attribute of our in individuality, but it also means that no two people respond to care in exactly the same manner. We take pride in our ability to offer innovative, science-based approaches in the attempt to address what, for many, are profound limitations in their function and quality of life. We look forward to partnering with you and your support community to explore what your individual responses may bring to your life and your future.
2 Patient Data Date Mr. Mrs. Ms. Miss (check one) First Name: Middle Initial: Last Address: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Date of Birth: / / Age Gender: Male Female Home Marital Status: (check one) Married Single Other Employment Status: Race: Employed Full time Student Part time Student Other White Black/African American Hispanic American Indian / Alaskan Native Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian or other Pacific Island Samoan Guamanian or Charmorro Other I choose not to specify Multi-Racial (check one) Yes No Unknown English Spanish American Chinese French German Sign Language Tagalog Vietnamese Italian Korean Russian Polish Arabic Portuguese Japanese French Greek Hindi Creole Persian Udru Gujarati Armenian German I choose not to specify
3 Verification Question (choose only one question by placing a check mark in the box, then write your answer to the question). What is the name of your favorite pet? In what city were you born? What high school did you attend? What was the make of your first car? What is your mother's maiden name? On what street did you grow up? What is your favorite movie? When is your anniversary? Verification Answer to the Chosen question Answers must be, at least 6 characters. Do you currently smoke tobacco of any kind? Yes Former smoker Never been a smoker If yes, how often do you smoke: Current every day smoker Current sometimes smoker If yes, what is your level of interest in quitting smoking? Current medications, including frequency and dosage if known. If there are no current medications, check here: Start Date of Medication List any known allergies you have had to any medications If no allergies are known, check here: Briefly list your main health problems Has any doctor diagnosed you with Diabetes presently? Yes No If yes to Diabetes was your blood lab-work test for hemoglobin A1c>9.0%? Yes No If yes, other comments regarding Diabetes: Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days? Yes No To be performed by clinic staff Height: inches Weight: pounds BP: /
4 Is it ok to call you at work? Yes No How did you hear about our clinic? Or who referred you? Family Member Attorney Internet Website Health Class Friend Yellow Pages Billboard Brochure Physician Newspaper Ad TV Commercial Direct Mail Ad Employer Sign on Building Radio Other If you selected Yellow Pages, please indicate which Yellow Pages: If you selected family member, friend, or physician please enter the name below: If selected other please describe: Medical Conditions: Arthritis Cancer Diabetes Heart Disease Hypertension Psychiatric Illness Skin Disorder Stroke Surgeries: Appendectomy Cardiovascular procedure Cervical disc procedure Joint replacement Laminectomies Radical prostatectomy Hysterectomy Allergies: Eggs Fish and Shellfish Milk or Lactose Peanut Soy Sulfites Wheat/Gluten Social History: Transuretheral prostate surgery Caffeine used occasionally Drink alcohol occasionally Exercise often Smoke more than 1 pack a day Caffeine used often Chew tobacco occasionally Chew tobacco often Drink alcohol often Exercise not at all Exercise occasionally Experience stress occasionally Experience stress often Smoke 1 pack or less per day Wear seat belts always Wear Seat belts never Wear seatbelts usually Family History: Arthritis (parent) Arthritis (sibling) Cancer (parent) Cancer (sibling) Cholesterol (parent) Cholesterol (sibling) Diabetes (parent) Diabetes (sibling) Heart problems (parent) Heart problems (sibling) High blood pressure parent) High blood pressure sibling) Psychiatric (parent) Psychiatric (sibling) Stroke (parent) Stroke (sibling) Thyroid (parent) Thyroid (sibling) Substance Use: Alcohol (past) Alcohol (present) Amphetamines (past) Amphetamines (present) Barbiturates (past) Barbiturates (present) Cocaine (past) Cocaine (present) Crystal Meth (past) Crystal Meth (present) Heroine (past) Heroine (Present) Marijuana (past) Marijuana (present)
5 Male Children: Under 6 years Under 10 years Under 19 years Female Children: Under 6 years Under 10 years Under 19 years Occupational Activities: Administration Business Owner Clerical/Secretarial Computer User Construction Daycare/Childcare Executive Legal Food Service Industry Healthcare Heavy Equipment Operator Heavy Manual Labor Home Services Household Light Manual Labor Manufacturing Medium Manual Labor
6 By using the key below, indicate on the body diagram where you are experiencing the following symptoms: # = Numbness X = Burning I = Stabbing 0 = Pins & Needles + = Dull Ache Describe your symptoms: When did your symptoms start? Month Day Year How did your symptoms begin? How often do you experience your symptoms? Constantly Frequently Occasionally Intermittently (75-100% of the day) (51-75% of the day) (26-50% of the day) (0-25% of the day) What describes the nature of your symptoms: Sharp Dull Ache Numb Shooting Burning Tingling Stabbing How are your symptoms changing? Getting Better Not Changing Getting Worse During the past 4 weeks, indicate the average intensity of your symptoms: (0 = None to 10 = Unbearable) 0 None Unbearable
7 During the past 4 weeks, how much has pain interfered with your normal work (including both work outside the home and housework? Not at all A little bit Moderately Quite a bit During the past 4 weeks, how much of the time has your conditions interfered with your social activities? All of the time Most of the time Some of the time A little of the time None of the time In general, would you say your overall health right now is. Excellent Very good Good Fair Poor Who have you seen for your symptoms? No one Other Chiropractor Medical Doctor Physical Therapist What treatment did you receive for your symptoms? Adjustments Physical Therapy Medication Surgery When did you receive this treatment? In the last month 2 3 months ago 3 6 months ago 6 months to 1 year ago 1-2 years ago 2 5 years ago 5 10 years ago What tests have you had for your symptoms? X-ray MRI CT Scan Other When were these tests done? In the last month 2 3 months ago 3 6 months ago 6 months to 1 year ago 1-2 years ago 2 5 years ago 5 10 years ago 1-2 years ago Have you had similar symptoms in the past? Yes No If you have seen treatment in the past for the same or similar symptoms, who did you see? This Office Other Chiropractor Medical Doctor Physical Therapist Other What is your occupation? Professional/Executive White Collar Secretarial Tradesperson Laborer Homemaker Full-time Student Retired Other If you are not retired, a homemaker or a student, what is your work status? Full-time Part-time Self-employed Unemployed Out of work Other Thank you. Please return to the front desk.
8 Have you had trouble with any of the following: Cardiovascular No Respiratory No Poor Circulation Asthma High Blood Pressure Tuberculosis Aortic Aneurism Shortness of Breath Heart Disease Emphysema Vascular Disease Cold/Flu Heart Attack Cough/Wheezing Chest Pain High Cholesterol Pace Maker Jaw Pain Irregular Heartbeat Swelling of Legs Genitourinary No Ears/Nose Throat No Kidney Disease Dizziness Lower Side Pain Hearing Loss Burning Urination Sinus Infection Frequent Urination Nosebleed Blood in Urine Sore Throat Kidney Stone Difficulty Swallowing Bleeding Gums Hematologic/Lymphatic No Eyes No Hepatitis Glaucoma Blood Clots Double Vision Cancer Blurred Vision Easy Bruising Easy Bleeding Fever/Chills/Sweats Allergic Immunologic No Integumentary No Hives Skin Lesions Immune Disorder Skin Ulcers HIV/AIDS Skin Disease Allergy Shots Eczema Cortisone Use Psoriasis Rashes Gastrointestinal No Psychiatric No Gallbladder Problems Depression Bowel Problems Anxiety Disorder Constipation Unusual Stress Liver Problems Ulcers Diarrhea Nausea/Vomiting Bloody Stools
9 Have you had trouble with any of the following: Poor Appetite Musculoskeletal No Endocrine No Gout Thyroid Disease Arthritis Diabetes Joint Stiffness Hair Loss Muscle Weakness Menopausal Osteoporosis Menstrual Problems Broken Bones Joints Replaced Constitutional No Neurological No Weight Loss/Gain Babinski Energy Level Problem Stroke Difficulty Sleeping Seizures Head Injuries Brain Aneurism Numbness Severe Headaches Pinched Nerves Parkinson s Disease Carpal tunnel Spinning/Balance
10 Patient Data Date Mr. Mrs. Ms. Miss (check one) First Name: Middle Initial: Last Address: City: State: Zip Code: Home Phone: ( ) Cell Phone:( ) Work Phone: ( ) Date of Birth: / / Gender: Male Female Social Security Number: - - Employment Status: Employed Full time Student Part time Student Other Spouse Data Is your spouse a patient in the clinic? Yes No First Name: Middle Initial: Last Home Phone: ( ) Employer Data: Name: Address: City: State: Zip Code: Emergency Contact Data: Contact: Contact Phone: ( )
Employment Status: Employed FT Student PT Student Retired Self Employed Other
COMPLETE HEALTH Date: / / PATIENT INFORMATION First Name: Home Phone: ( ) - Last Name: Work Phone: ( ) - Date of Birth / / Sex: M F Cell Phone: ( ) - Address: Apt. # Is it ok to call you at work?: Yes
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Athens Rheumatology Clinic, LLC Sana Makhdumi, MD
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PERSONAL INJURY QUESTIONNAIRE
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PATIENT DATA ADDRESS: CITY: STATE: ZIP:
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Past Medical History. Chief Complaint: Appointment Date: Page 1
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HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
Medical History Form
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Florida Hospital Spine Center Patient Intake Form
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Morris Medical Center, P.A.
Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~
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
Occupation: Leisure Activities: ALLERGIES Are you latex-sensitive? Y N List any medication(s) you are allergic to:
Hello and thank you for choosing Fusion Physical Therapy as the provider for your current healthcare need(s)! We look forward to working with you to help make your day a little easier! To ensure you receive
DEPARTMENT OF NEUROSURGERY Spine Center New Patient Intake Form
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HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City: