(Must be completed with blue ink pen) Last Name First Name Date / / Address City Zip. Home Phone Cell Phone. Social Security# Driver s License # State

Transcription

1 (Must be completed with blue ink pen) (MR #: ) Last Name First Name Date / / Address City Zip Home Phone Cell Phone Birthday / / Sex: M F Social Security# Driver s License # State Occupation Employer Marital Status: Spouse s Name Number of Children: Emergency Contact (name) (phone) (relationship) Insurance Company: Insurance ID Group #: Name & Date of Birth of Policy Holder: How did you hear about our clinic? How would you like to receive appointment confirmations? Text (Cellular Carrier ) None Medications/Supplements Please list all medications that you are currently taking. See attached list Please list vitamin, mineral, and herbal supplements you are currently taking. See attached list C:\Users\Jon.Mills\Downloads\New Patient Intake Form OSST Website.doc Revised: December 15,

2 Family History Has any member of your family been diagnosed with any of the following: Cancer Diabetes High Blood Pressure Stroke Heart Disease If yes, what is their relation to you? Vascular Screening Symptoms Have you recently experienced any of the following? (mark all that apply): Dizziness Fainting / Loss of Consciousness Recent Decrease in Coordination Trouble Swallowing Nausea/Vomiting Slurred Speech Recent Unexplained Weight Gain or Loss Change in Urination Blurred Vision, Double Vision, or Visual Disturbances (other than those associated with normal aging or corrected with glasses or contacts) None of the above. If you are experiencing Headaches or Neck Pain, have you experienced pain like this before? Yes, I have had headaches / neck pain like this before. No, this pain is different than I have experienced in the past. Is your headache worse in the morning or afternoon? Do your headaches wake you from your sleep? Y/N Previous/Current Conditions Do you currently have or have you ever had any of the following: Allergies: Aneurysm Anemia Arthritis: Asthma Bone Fractures (list/date): Blood Pressure HIGH/LOW Cancer/Tumor Carotid Artery Disease or Blockage Change in Appetite Diabetes Dislocated Joints Easily Bruised Emphysema Epilepsy/Seizures Erectile Dysfunction Fatigue/weakness Frequent Nose Bleeds Hearing Changes Heart Disease Heart Palpitation Hernia HIV/AIDS HYPER/HYPO Thyroid Insomnia Kidney Trouble Liver Trouble Mental/Emotional Difficulty: Multiple Sclerosis Osteoporosis/Osteo penia Pacemaker Polio Prostate Trouble Rash/Lesion Rheumatic Fever Scoliosis Spinal Disc Disease STD Stroke Tinnitus/Ears Ringing Tuberculosis Ulcer Other None of the above Do you experience any of the following: limitations to your ability to walk (including fatigue), instability, disequilibrium or dizziness?

3 Miscellaneous Headache Other: How would you rate your pain on a scale of 1 (best) to 10 (worst)? Currently: At Its Best: On Average: At Its Worst: Please rate each of your symptoms individually on a scale of being no pain at all and 10 being the most pain you have ever had. Symptom #1: Symptom #2: When did your symptoms begin? What was the cause of your symptoms? Other How soon did the symptoms start? Later Other Have you experienced symptoms like these before? No Yes (when?) Have you missed any work due to this condition? No Yes If yes, give recent dates: Have you had to modify or restrict your activities at work? No Yes (If yes, we will have you complete forms that address restrictions to your Activities of Daily Living.)

4 What aggravates your condition? Coughing Sneezing Baring Down Lifting Bending Pushing Pulling Sitting Standing Lying Down Walking Moving Your Head Other What alleviates your condition? Rest Movement Sitting Standing Lying Down Bracing Heat Ice Massage Stretching Popping Aspirin Ibuprofen Tylenol/Acetaminophen Prescribed Medication Other How would you characterize your pain? (check all that apply): Dull Sharp Achy Shooting Burning Stabbing Throbbing Stiffness Other What time of the day are your symptoms worse? Morning Afternoon Evening While Sleeping At Work Other: What time of the day are your symptoms better? Morning Afternoon Evening Sleeping At Work Other: Are your symptoms getting: Better Worse Staying the Same When your symptoms are at their worst describe what happens. What three things has this caused you to miss out on the most? 1) 2) 3) What is your biggest concern if you are unable to find a solution to your main problem? Please indicate how important it is for you to improve your current condition, or stop it from progressing. Not Important Very Important Previous Testing What testing have you had done and when? X-ray: Y/N Area: Date MRI: Y/N Area Date CAT Scan: Y/N Area Date Electrodiagnostic Tests (EMG/NCV): Y/N Area Date Was there a previous diagnosis for your condition, have you been told what is causing your symptoms? Previous Treatment Have you ever seen anyone else for this condition? Yes No If Yes, who and when?

5 What were the results from each type of treatment? Treatment Options Is there any type of treatment that you would not consider at this time? What is your most important treatment objective? (Reduce pain, increase function, correct cause, prevent progression) Previous Accidents/Injuries/Hospitalizations/Surgeries Please inform us of any/all recent injuries that could have contributed to your current condition, even if you re not sure whether or not it is related to your condition. Do you have a history of any of the following? Work Injury Auto Accident Slip and Fall Accident If so please list approximate dates and incident: 1.Date / / Incident 2. Date / / Incident Have you ever been hospitalized? Yes No If so, when and for what condition? 1. Date / / Condition 2. Date / / Condition Have you had any surgeries? Yes No If so, when and for what condition? 1. Date / / Surgery 2. Date / / Surgery Women Only Is there any chance that you may be PREGNANT? Y/N Date of last menstrual period / /

6 Sleep Habits Please answer the following questions about your sleep habits: Do you have trouble falling asleep due to being uncomfortable? Y/N How long does it take to fall asleep? Do you wake during the night? Y/N Approximately how many times? Can you get back to sleep? Y/N Activities of Daily Living This next series of questions are about the effect your condition has had on your activities of daily life. We also will use this information to measure your progress and the results of your treatment if we are able to accept you for care. Work How do your health problems make it harder to do your job? Are you less productive on your job because of your health problems? Yes No Do you enjoy work less? Yes No Do you have to take more breaks? Yes No Are you concerned about your ability to do your job or the security of your job? Yes No Please explain Social How do your health problems affect your relationships with your family and friends? For example: Are you less fun to be with? Do you help less around the house? Are there things you do less? Recreational Activities What hobbies or interests do you have outside of work? When your problems are at their worst, do they affect how you do or enjoy your hobby/interest? Yes No If you didn t have this condition how would it affect how you do your hobbies/interests? Is there anything else you would do more of or just enjoy more if it wasn t for these conditions? Life Style Habits Smoking (packs per day): Never Quit years ago.

7 Caffeinated drinks (glasses per day): Alcohol consumption (glasses per day): Drug/Substance use: Yes No Exercise (times per week): Type of exercise Average amount of sleep per night (hours): What do you feel your stress level is currently? (0 being no stress and 10 being maximal stress) Additional Information-Resources If you are interested in receiving additional information about any of the following, please check the boxes below: Conditions Peripheral Neuropathy Sciatica Chronic Headaches Dizziness/ Balance Disorders Whiplash Injuries Mild Traumatic Brain Injury Chronic Back/Neck Pain Joint Pain (Hip, Knee, Foot, Shoulder, Elbow, Hand) Treatments Non-Surgical Spinal Decompression Cold Laser Massage Therapy Clinical Nutrition Functional Neurology Vitamins/ Supplements Infrared Therapy Whole Body Vibration Interactive Metronome