David Saperstein, MD Center for Complex Neurology.
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- Jerome Freeman
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1 Patient Name: Patient DOB: Patient Phone: Patient David Saperstein, MD Center for Complex Neurology Ph Fax I am pleased that you are seeking my help with your medical issues. In order to best help you, I ask that you please complete this form. I realize it is very lengthy, but getting this information prior to your appointment will save time and, therefore, give us more time during your appointment to discuss all the issues that are bothering you. When you come to your appointment, please bring any records that you have (such as radiology reports and discs). On the day of your appointment you might be seen first by a nurse practitioner, but I will personally speak with you and examine you as well. I appreciate your working with me and my office to facilitate your evaluation at Phoenix Neurological Associates. I look forward to seeing you. David Saperstein, MD
2 Please answer the following questions as best as you can. Check the box for any condition you have been diagnosed with. Ehlers-Danlos Syndrome (EDS) Joint hypermobility syndrome (JHS) Postural orthostatic tachycardia syndrome (POTS) Dysautonomia Syncope Mitral valve prolapse Gastroparesis Irritiable bowel syndrome (IBS) Celiac disease Gluten sensitivity Intersitital cystitis Migraines Chiari malformation Tempormandibular joint dysfunction (TMJ) Neuropathy Pinched nerve in neck Pinched nerve in back Mast cell activation syndrome (MCAS) Asthma Raynauds Depression Anxiety ADHD Bipolar PTSD Autoimmune disease Polycystic Ovary Syndrome
3 JOINTS Please check the box if you have any of these symptoms Double jointed Pain in joints Joints slide in and out of place Dislocated joints (you have to do something to get the joint back into place) Check which joints are involved Shoulders Elbows Wrists Fingers Ribs Hips Knees Ankles Toes PAIN AND HEADACHES Neck pain Neck pain that shoots into arms or hands Back pain Back pain that shoots into hips or legs Numbness or tingling on a frequent basis Check where numbness or tingling occurs Face Arms Hands Chest Stomach Legs Feet
4 Headaches How often are the headaches? More than 3 times per week 1 to 2 per week 1 to 2 per month less than 1 per month Where are the headaches? Back of head Front Temples Behind eyes All over Do any of these occur with your headaches? Nausea Vomiting Light sensitivity Sound sensitivity Seeing flashing lights or zig-zagging lines What to you do when you get a headache? What medications have you tried in the past (to take during a headache or to prevent headaches)? Check if any of these apply to your jaw Pain Popping Clicking Difficulty chewing Jaw gets stuck or dislocates Treated for TMJ Currently using a mouth guard
5 LIGHTHEADEDNESS Check if you get any of these symptoms Light headedness with standing Light headedness or dizziness while sitting or lying down Rapid heart beat Chest pain Shortness of breath Tunnel vision or vision going black or white Fainting Sweating too much Not sweating enough Check if the above symptoms worsen after any of these activities Eating Showering Going outside in the heat GASTROINTESTINAL Check if you are bothered by any of these symptoms Stomach pain Stomach bloating or getting full easily Nausea Vomiting Diarrhea Constipation Sensitivity to foods Which foods? GENITOURINARY Check if you are bothered by any of these symptoms Dry mouth Dry eyes Urinating frequently Trouble urinating Urinary incontinence (loss of urine)
6 Problems affecting sexual relations Decreased sex drive Pain with sex Trouble getting an erection Menopause Vaginal dryness SLEEP AND ENERGY Check if you have any of these problems Trouble falling asleep Trouble staying asleep Sleepiness during the day Trouble concentrating Trouble remembering things Brain fog SKIN Check if you are bothered by any of these issues Change in skin color in hands or feet Easy bruising Frequent rashes Hives Anaphylaxis Flushing or warm feeling in face or chest Trouble getting numb from local anesthetics Poor healing after surgery or injuries PREGNANCY (FOR WOMEN) How many time have you been pregnant? How many children do you have? Check if you had any of these pregnancy complications Preterm labor Premature rupture of membranes Uterine rupture Miscarriage
7 FAMILY HISTORY List any relatives who have symptoms like yours How many sisters do you have How many brothers do you have How many brothers or sisters does/did your mother have How many brothers or sisters does/did your father have Check if anyone in your family had any of these conditions Aneurysms Ruptured organs Migraines Seizures Mental retardation Hearing problems before age 40 Vision problems before age 40 Have you ever had genetic testing? Yes No Has anyone in your family had genetic testing? Yes No SUMMARY On a day to day basis, what 2 or 3 things bother you the most? On a scale of zero to ten rate how much you are bothered by: Joint problems Feeling anxious Headaches Brain fog Neck pain Fatigue Back pain Trouble sleeping Other pain Digestive problems Lightheadedness Allergic reactions Rapid heart beat
8 PRIOR EVALUATION AND TREATMENT Check the box for any of the following specialists you have seen Allergist/Immunologist Cardiologist Endocrinologist Gastroenterologist Geneticist Neurologist Neurosurgeon Orthopedist Pain Specialist Psychiatrist Psychologist/Therapist Rheumatologist TMJ Specialist Check the box of any of these tests you have had Echocardiogram Holter monitor Tilt table test Autonomic reflex test Nerve conduction studies (NCS) Electromyogram (EMG) Electroencephalogram (EEG) Gastric emptying study Colonoscopy/Endoscopy MRI brain MRI cervical spine MRI lumbar spine Allergy testing
9 Have you had P.T.? Yes No Are you currently in P.T.? Yes No Have you had O.T.? Yes No Are you currently in O.T.? Yes No Do you use any braces? Yes No If yes, what areas do you have braces for Have you ever been given injections to treat pain? Yes No If yes, where in your body and when? Check the box of any medications that you are taking or have tried in the past Atenolol (Tenormin) Clonidine (Catapress) Fludrocortisone (Florinef) Ivabradine (Corlanor) Metoprolol (Toprol) Midodrine (Proamatine) Nadolol (Corgard) Northera (Droxidopa) Propranolol (Inderal) Pyridostigmine (Mestinon) Adderall (dextroamphetamine) Alprazolam (Xanax) Amitriptyline (Elavil) Botox Clonazepam (Klonopin) Diazepam (Valium) Duloxetine (Cymbalta) Gabapentin (Neurontin) Fentanyl (Duragesic) Hydrocodone (Vicoden) Lorazapma (Ativan) Low dose naltrexone (LDN)
10 Lyrica (Pregabalin) Medical Marijuana Methylphenidate (Ritalin) Morphine Oxycontin (Oxycodone) Opana (Oxymorphone) Nortriptyline (Pamelor) Nucynta (Tapentadol) Savella (Milnacipran) Straterra (atomoxetine) Topiramate (Topamax) Tramadol (Ultram) Valproic acid (Depakote) Venlafaxine (Effexor) Vyvanse (lisdexamfetamine) Check any of these non medication treatments you have used Acupuncture Chiropractic Compression stockings Exercise Elevating head of bed Hypnosis IV fluids Massage High salt intake Gluten-free diet Low histamine diet Yoga
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Thank you for choosing Therapy Works to assist you with your current condition.
Therapy Works Welcome Packet Thank you for choosing Therapy Works to assist you with your current condition. Please fill out the enclosed paperwork and bring back with you to your appointment. Important
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
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:
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
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:
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
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
Please describe, in detail, when the symptoms began:
161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On
California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)
California Chiropractic Boshears, Inc. 35191 Yucaipa Blvd., Yucaipa Ca. 92399 Phone: (909) 790-5005 Fax : (909) 790-5009 Patient Information Date: Name: Address: Home Phone: Work Phone: Sex: Male or Female