Initial Patient Health Assessment Form
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- Marlene Sutton
- 5 years ago
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1 Initial Patient Health Assessment Form General Information: Patient Name:, Date: / /20 Patient s Address:. City:, State:, Zip Code: Home Phone #: - -, Work Phone #: - -, Cell #: - - address:, Date of Birth: / / Social Security #: - -. Sex: M, F, Patient Occupation:, Patient s Employer/School:. Patient s Employer/School address:. Patient s Employer/School Phone #: - - Health Insurance Plan:, Group #: Member ID #:, Other Health Insurance:, Group #: Member ID #:. *Name of Insured (if other than you):. Relation to Patient:, Date of Birth: / / Insured Social Security #: - -. Insured s Employer:. Who may we thank for referring you to the office for treatment?. Health Insurance Plan:, Group #: Member ID #:, Other Health Insurance:. In case of an Emergency, contact: Name: Relationship:, Home #: - -, Work #: - -, Cell #: - -, 1
2 Symptom/Condition History: 1) Please describe your current condition and how the problem began: 2) How long have you had this problem? 3) What caused your problem? (Check appropriate box below) or explain: Auto accident Work related accident Gradual Sudden other type of accident, please explain below: 4) How would you describe your pain? (Mark all that pertains to your pain) Sharp Soreness Throbbing Tingling Dull Stiffness Spasm Burning Ache Weakness Numbness Shooting 5) How would you rate the intensity of your pain right now? (Circle a number) (No Pain) (Minimal) (Mild) (moderate) (severe) (unbearable) 6) How often is the pain present during your waking day? (Check appropriate box) 0% 7) Pain Scale: 0 is no pain & 10 is the worst possible pain, please circle the number below that indicates the amount of pain you are experiencing right now (No Pain) (Minimal) (Mild) (moderate) (severe) (unbearable) 8) Since your problem began, is your pain getting, Better, Worse, Staying the same. 9) What makes your problem better? Nothing Walking Standing Sitting Lying down Moving Rest Others: 10) What makes your problem worse? Others: 2
3 Symptom/Condition History Continued: 11) Are you currently taking any medications for this condition or any other conditions? Please name your condition(s), the medications name, the amount taken daily (mg), and how many times a day you take the medication (1/2/3etc ). 12) Do you take any vitamins, herbs, or nutritional supplements?, the product, the amount taken daily (mg), and how many times a day you take them (1/2/3etc ). 13) Were you previously treated for this condition?, No, if yes, in your own words please describe below which professional provider diagnosed your condition, and the outcome of the treatment. Please explain in detail: 14) What were the approximate dates of your treatments, the type of treatments, and your response to your treatments? 15) How physical is your activity at work? Mostly sitting Light manual Moderate manual Heavy manual 3
4 Symptom/Condition History Continued: 16) Do you exercise? No regular exercise 1-2 times/week 3-4 times/week 5-7 times/week Cardiovascular Stretching Weight Machine Free Weights Please explain: and/ or, Please explain: 17) What is your general stress level? No Stress Minimal Stress Moderate Stress Very Stressed 18) Is your problem affecting your ability to work or do other routine daily activities? No effect Have some restrictions but can function cannot work totally disabled On the Anatomical Diagram below Please mark with the letters below where you are experiencing pain or other symptoms right now. A = ACHE, B = BURNING, N = NUMBNESS, S = STABBING, P/N = PINS & NEEDLES (TINGLING), S/S = SHARP SHOOTING, W = WEEKNESS IN MUSCLES OTHERS: Right Left Left Right Front Back 4
5 Family History Please review the list below of diseases and conditions and Mark an X to indicate any current health conditions of a family member. Please leave the spaces blank that do not apply to any family member. If you where adopted please mark please leave the Family History blank. Conditions Back Conditions Neck Conditions Disc Problems back Neuritis Neuralgia Pinched nerve Scoliosis Epilepsy Osteoarthritis Rheumatoid Arthritis Bursitis Depression Stomach Conditions Constipation Headaches Migraine Headaches Asthma-Hay Fever Sinus Conditions Lung Conditions Emphysema COPD Heart Conditions By Pass Hypertension Kidney Conditions Liver Conditions Cancer Insomnia Diabetes Type I Diabetes Type II Father Mother Spouse Brother(s) Sister(s) Children(s) Age ( ) Age ( ) Age ( ) Age ( ) Age ( ) Age ( ) Age ( ) Age ( ) Age ( ) If the above parents or siblings were deceased, how old were they, and what condition did they pass away from? 5
6 Past or Present Symptoms, Conditions or Habits: Please check the box indicating whether this applies to past or present. Symptoms/Conditions: Past Present Diagnosis Date *Rheumatoid arthritis Osteoarthritis Ankylosing spondylitis Bone fractures: Malignancy of the spine Infection of the bones or joints Myelopathy Cauda Equina syndrome Carotid artery problems Aneurysm *Instability of joints Benign tumors of the spine Osteoporosis Bleeding disorders Nerve problems Multiple Sclerosis Anticoagulants/blood thinning therapy *Dizziness Drop Attacks Double vision Difficulty speaking Difficulty swallowing Nausea Numbness Nystagmus Neck pain Jaw pain TMJ/TMD Headaches: Type: Fainting spells High blood pressure Stroke Transient ischemic attacks *Shoulder pain Arm/ and pain Neck Pain Upper back pain Lower back pain Hip pain Knee pain Ankle/ Foot pain / / 6
7 Past or Present Symptoms, Conditions or Habits Continued: Symptoms/Conditions: Past Present Diagnosis Date Fatigue Respiratory condition Digestive problems Kidney problems Menstrual problems Sinus/ allergy/ asthma conditions Weight Gain/ oss lb Cancer Type: Skin condition Diabetes: I / Prostate problems *Tobacco use: # Packs per day brand of cigarettes:, Onset of smoking: / /, how many years have you been smoking?. Alcohol use: # of drinks per day, type of Alcohol: & Other liquor:. Caffeine use: # of Cups per day. Pregnancy: * Pregnancy Vaginal Delivery Dates: / /, / /, / / * Pregnancy C-Section Delivery Dates: / /, / /, / / Epidural Injections: how many, and dates: / /, / /, *Surgery Dates: / /, / /, / /, / /, Surgery: Please explain what type of surgery you had in the past: *Is there any other condition or information that you feel is important to you and would like Dr. Rooney to be aware of and if so, please explain:? Patient s Signature:, Date: / /20 Guardian Signature:, Date: / /20 (If the patient is a minor) 7
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PATIENT REGISTRATION
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Adult New Patient Intake. Your Health Summary
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LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
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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.
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Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
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Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
Name_ Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) For reminders do you prefer Phone Calls, Text Messages or Emails? CALL ME / TEXT ME / EMAIL ME Email Address
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Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
Subjective Medical History Information
Page 1 of 8 Date: Patient Account #: Patient Name: Insurance: Date of Birth: History of current condition 1. Which of the following best describes how your injurt occurred? (if your injury is post-surgical
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
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM Which Chiropractor are
Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program
Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program If you are reading this you have been fortunate enough to qualify for a consultation with Dr. Zammito at
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C. 2407 Lenora Church Road / Snellville, Georgia 30078-6916 / 770-979-2731 Welcome to our office! Today's Date: / / Your Name: [ ] Male [ ] Female What
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
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
PATIENT PERSONAL / CONFIDENTAL DATA
PATIENT PERSONAL / CONFIDENTAL DATA Address: City: State: Zip Code : H. Phone: W. Phone: Cell Phone: Date of Birth: Age: Sex: M F Marital Status: M S D W Email Address: Social Security # Name of Spouse:
MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History
MEDICAL INFORMATION TODAY S DATE: SOCIAL SECURITY NUMBER: PATIENT NAME: BIRTHDAY: HEIGHT: WEIGHT: AGE: WHO REFERRED YOU? RACE: PRIMARY CARE PHYSICIAN: SEX: DOCTOR S ADDRESS: SECTION 1: Pharmacy Information
PATIENT REGISTRATION
PATIENT REGISTRATION "Please PRINT clearly and fill out form COMPLETELY and hand all insurance cards for copying ** First Name: Last Name: Middle Initial: Address: Apt #: City: State: Zip: Date of Birth:
Family First Chiropractic
Family First Chiropractic Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of
Consent to Treat a Minor
1. Fill out the application for treatment sheets, two of them, and sign both of them accordingly. 2. If the appointment is for a minor, please read the Consent to Treat a Minor carefully and sign accordingly.
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska 99518 (907)563-7700 PATIENT DEMOGRAPHICS Today's Date: *** PLEASE WRITE IN BLACK