Providence Neurosurgery PATIENT INFORMATION SHEET
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- Britton Thornton
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1 Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician City Name of primary care provider/physician: Are you currently being treated by a chiropractor? No Yes If yes, name: Are you currently being treated by a physical therapist? No Yes If yes, name: May we send information about your treatment here to the above practitioners/physicians? No Yes Explain briefly why you are being seen: Date of injury/onset: Circumstances of injury/onset: Have you ever had similar problem? No Yes If yes, please describe: Drug Allergies and Reactions (Please list allergy and reaction): Allergy Reaction Are you allergic to any of the following: Shellfish No Yes X-ray contrast No Yes Metal No Yes Latex/rubber No Yes Costume Jewelry No Yes Soap No Yes Iodine No Yes Tape No Yes Page 1 of 5
2 Current Medications (please include all prescription, over-the-counter drugs, birth control pills and vitamins) Name of Medication Reason Dose Frequency Past Medical History (please check any current or past problems) Depression Thyroid Disorder Blood abnormality Stroke Lung Disease Anemia Heart Disease/attack Seizures Ulcers Bleeding disorder High blood pressure Pacemaker Hepatitis Tick Bites HIV or exposure Glaucoma Liver abnormality Cancer Diabetes yr onset Rash Asthma Sleep apnea Back pain child/adult Psoriasis Arthritis Kidney/bladder problems Other Blood clot or deep venous thrombosis (DVT) Do you have a current gum or dental infection? No Yes Surgery History: Surgery Name Surgery Date Location where performed 1. No Yes Have you had surgical complications? 2. No Yes Have you had an adverse reaction to general anesthesia? 3. No Yes Have any immediate family members had an adverse reaction to general anesthesia? 4. No Yes Have you had a blood transfusion? Approximate year: 5. No Yes Is there any reason you could not receive blood if needed during surgery? 6. No Yes Are you pregnant? Page 2 of 5
3 Social History Are you currently: Single Married Separated Divorced Widowed Domestic Partner Are you currently employed? No Yes Occupation: No Yes Do you currently use tobacco? If yes, do you: No Yes Smoke cigarettes How many per day? Years of use No Yes Cigar/pipe How many per day? Years of use No Yes Chew tobacco How many cans per week? Years of use No Yes Are you a former smoker/tobacco user? If yes, what age did you quit: No Yes Have you ever used recreational/non-medical drugs? If yes, type: No Yes Do you use alcohol? If yes, amount per day or week: Family History (Please describe the health history of your family members) Relationship Spouse Age (at death if deceased) Health Status (living or deceased) Medical problem or cause of death Mother Father Page 3 of 5
4 Please mark any of the following you are experiencing: Constitutional: Head/Ear/Eyes/Nose/ Respiratory: Throat: Loss of appetite Loss of vision Coughed blood Fever or chills Headache Asthma/ wheezing Chronic Fatigue Hearing difficulty Cough Recent infections Eye or mouth dryness Shortness of breath Problems sleeping Cardiovascular: Other: Weight loss Chest pain Menstrual difficulty Weakness Irregular heartbeat Stiff joints Bleeding disorder Circulation problems Swollen joints GI/GU: Neurological: Abdominal pain Dizziness Poor coordination Nausea Impaired thinking Seizure Constipation Ringing in ears Numbness/tingling Bloody urine Lack of bladder control Speech difficulty Vomiting Difficulty with taste/smell Blackouts or fainting Heartburn Memory problems Meningitis, encephalitis Stomach ulcer Difficulty walking Swallowing difficulty Diarrhea Back, neck, head injury Sexual function problems Bowel incontinence Depression Decreased attention Black/bloody stools Tremor or shaking Personality changes Double vision Other symptoms you have experienced (please describe): Page 4 of 5
5 Mark the areas on your body where you feel the described sensations. Use the appropriate symbol. Include all affected areas. Ache: AAAA Numbness: NNNN Burning: BBBB Stabbing: SSSS Tingling: TTTT AAAA NNNN BBBB SSSS TTTT FRONT BACK Please rate your pain on a scale of = none or least amount of pain 10 = most severe pain imaginable Today: Least: Worst: I attest all information I have provided is true and correct to the best of my knowledge. Patient Signature Physician Signature Date Date Page 5 of 5
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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
Date: Referring Physician Dr. Phone: Primary Care Physician (if different) Dr. Phone:
Kuether Brain and Spine Todd Kuether, MD 19250 SW 65 th Avenue, Suite 260 Tualatin, OR 97062 501 N. Graham, MOB II #515, Portland, OR 97227 (503) 489-8111 Phone (503) 908-6800 fax kuetherbrainandspine.com
Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother
Silver Child Development Center New Patient Questionnaire Today s Date Mother s Name First Last Date of Birth Relation (circle) Biological Mother Stepmother Adoptive Mother Foster Mother Other Father s
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription