Medical History Questionnaire
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- Charla Payne
- 6 years ago
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1 Date Medical History Questionnaire Name DOB Reason for visit When did symptoms first appear Is the condition getting worse? Please rate your pain No Pain Extreme Pain Please circle the area of the body that hurts and circle any of the words that describe your discomfort.
2 How often do you have this pain? Constantly (76-100% of the day) Occasionally (26-50% of the day) Frequently (51-75% of the day) Intermittently (0-25% of the day) Does it interfere with work sleep daily activities recreation What activities aggravate your condition? (Check all that apply) Standing Sitting Walking Bending Tension Lack of Sleep Lying Down Lifting Driving Reaching Over Head Sexual Activity Working on the Computer Rainy Weather What makes your pain better? (Check all that apply) Lying down Walking Sitting Standing Medication Sleep Heat Ice Massage Exercise Stretching Traction TENS Corset Biofeedback Compression Do you experience the following symptoms? (Check all that apply) Headaches Dizziness Memory Loss Concentration Deficits Nausea Vomiting Balance Disturbances Weakness Numbness Bowel Dysfunction Bladder Dysfunction Fatigue Irritability Difficulty Walking Depression Anxiety Weight Gain/Loss Swelling Color Changes Hair Loss Coldness Warmth Do you or have you ever suffered from the following medical conditions? Headaches High Blood Pressure Diabetes Neck Pain Heart Attack Excessive Thirst Upper Back Pain Chest Pains Frequent Urination Mid Back Pain Stroke Allergies Low Back Pain Liver Disease Depression Should Pain Kidney Stones Systemic Lupus Elbow/Upper Arm Pain Kidney Disorders Epilepsy Wrist Pain Bladder Infections HIV/AIDS Hand Pain Painful Urination Hip/Upper Leg Pain Bowel/Bladder Dysfunction Ankle/Foot Pain Prostate Problems Jaw Pain Weight Gain/Loss Joint Swelling/Stiffness Loss of Appetite Arthritis Abdominal Pain Rheumatoid Arthritis Ulcer
3 General Fatigue Muscular Incoordination Visual Disturbances Dizziness Hepatitis Gall Bladder Problems Cancer Tumor Indicate if you have a family history of any of the following: Rheumatoid Arthritis Multiple Sclerosis Diabetes Cancer Lupus Heart Disease High Blood Pressure Stroke What is your height and weight? Height Weight lbs Ft inches List all prescription and over-the-counter medication you are taking or attach list if you have one. List all surgical procedures you have had and the times you have been hospitalized: List all medication allergies or intolerances: Have you ever smoked? Presently Do you drink? Alcohol Coffee Tea Sodas Do you use recreational drugs? Are You: Single Married Separated Divorced Widowed Do you have children? How old are they? PLEASE COMPLETE THE FOLLOWING SECTION ONLY IF YOU WERE INJURED ON THE JOB OR INVOLVED IN AN ACCIDENT!!! Is this a work related injury or illness? Is this an accidental injury? Car Accident Fall Other: Date of injury: When did you first notice pain? Are you currently working? Full Duty Light Duty
4 Sitting hrs Standing hrs Lifting hrs Bending hrs Computer hrs Climbing Climbing Repetitive Motion If yes, then how many hours each day? What are your job responsibilities? Is your supervisor sympathetic to your needs? If you are not working, how long have you been out of work? Have you tired to return to work? Why did you stop? Does your Employer offer Modified Duty? Please list your work history (include how long you worked at your job before this injury occurred) If you were injured in a car, please check the appropriate descriptive: You were the: driver passenger in the: front rear Rear end collision broadsided sideswiped Was your seat belt on? Yes No Have you ever had a similar problem with pain? Please describe: Have you reported this accident to your Auto Insurance? Is there a Lawyer involved in your case? Name of Lawyer: Phone Number: Describe what happened (mechanism of injury): Was the onset of your pain? sudden gradual Did you go to the Emergency Room? When/Where? Check all diagnostic tests that were performed: Plain x-rays CAT scan
5 MRI EMG/Nerve Conduction Studies Myelogram/Discogram What treatment did you receive? How many hours per day do you have pain? (If you do not have pain every day, estimate how many hours of pain per week, month, etc.) How many weeks, months or years have you been disabled by pain? Do you occasionally need to stop all activities because of pain? If yes, number of times: daily weekly What activities are most affected by your pain? Please describe your usual daily routine: Describe your regular exercise routine and frequency: Do you have severe nighttime pain? Do you wake up in the middle of the night because of pain? If yes, then how many times? Do you have difficulty falling asleep at night? Do you wake up unusually early in the mornings? Previous Treatment (check all that apply) Temporary Relief Lasting Physical Therapy Modalities yes (ultrasound, hot packs, traction, electrical stimulation, soft tissue release, therapeutic exercise) Assistive Devices (wheelchair, walker, crutches, cane) yes TENS yes Biofeedback yes Mobilizations/manipulations Psychological support
6 Brace, splint, cervical collar Back school education Work hardening yes Injections (trigger point, facet block, nerve block, epidural, joint injection) Acupuncture yes Implants yes Pain Clinic Where? When? If you have seen or are currently seeing a Psychologist or Psychiatrist please list their name? Signature of Patient Date
REFERRED BY PAINFUL SIDE: RIGHT, LEFT, CENTRAL, RIGHT MORE, LEFT MORE, EQUAL ON BOTH SIDES, OTHERS DAILY PAIN: HRS MIN TIMES DAYS, WEEK, MONTH
NAME ADDRESS PHONE AGE DOB / / HT WT RACE MALE FEMALE SSN DATE OF ACCIDENT: / / REFERRED BY DATE OF VISIT CIRCLE APPROPRIATE ANSWERS OR EXPLAIN: 1. TYPE OF INJURY AUTO WORK OTHER PLEASE GIVE DETAILED EXPLANATION
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!
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New Patient Information
(Please Print) New Patient Information Name Address City/State/Zip Cell: Home: email: Social Security # Birthdate Age Male Female Occupation Employed by Wk ph. # Address City/State/Zip Number of Children
Date: Can we leave messages on voice mail at home/work/cell? Yes No. Sex: Male Female SS#: If yes, what type? Auto Work Other.
1 Patient Information : Name: Last First MI Email address: Mailing Address: Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Can we leave messages on voice mail at home/work/cell? Yes
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
Patient Intake Form. I prefer to receive calls at (circle) Home/Work/Cell I am (circle) Under Age18/Single/Married/Divorced/Widowed/Separated
Patient Information Full Name: First MI Last Patient Intake Form Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Social Security Number: Email Address: Home Phone: Work Phone: Cell/Other:
CHIROCENTER. Home Address: City: State: Zip: I would like to receive notifications Please do not send notifications
CHIROCENTER PATIENT ADMITTANCE Name: (First) (Middle Int). (Last) Today s : Home City: State: Zip: Telephone: Work: Cell: of Birth: Sex: M or F Social Security#: (Month) (Day) (Year) Circle if you are:
New Patient Form Date:
New Patient Form Date: Patient name: M F Date of Birth: / / SS# Address: City: State: Zip Code: Home Phone #: Cell #: Work #: Email: Emergency Contact: Emergency Phone #: Referred by: Primary Care Physician
PERSONAL INJURY QUESTIONNAIRE
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PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Personal Information: Name: Home phone #: Address: Alt. phone #: City/State/Zip: Email address: Date of birth: Age: Social Security #: Insurance Information: (Vehicle You
Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)
Patient s Name: Date: What is the reason for your visit today? Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone #
New Patient Pain Evaluation
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SPINE PROGRAM NEW PATIENT FORM
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NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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PATIENT INFORMATION FORM
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Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider
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
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
PERSONAL HISTORY AUTO ACCIDENT QUESTIONNAIRE. Personal Injury Questionnaire. Name Date. Date of Accident: Time. Location of Accident (Streets)
Personal Injury Questionnaire Patient# HISTORY OF OCCURRENCE Name Date Date of Accident: Time Location of Accident (Streets) As a result of the accident you were: Rendered unconscious In shock Dazed, circumstances
Initial Visit Forms. Life in Motion Chiropractic & Wellness 6139 Route 96 -Suite 1 Farmington, NY (585)
Initial Visit Forms 6139 Route 96 -Suite 1 Patient Name: Patient Intake Form Name: Date: Address: City: State: Zip: Home #: ( ) Cell #: ( ) Work #: ( ) E-mail: Preferred method of contact: Date of Birth:
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac. Personal History: Name: Address: City: Province: Postal Code: Birth date: day /month /year Age: Sex: M F Home Phone: Business Phone: Cell Phone: E-mail: Health
PAIN TREATMENT CENTER
PAIN TREATMENT CENTER Name Date Age Occupation Referring Doctor Have you ever been a patient of a Pain Clinic or Center? Yes No If yes where: When did you first notice symptoms of your pain problem? Date
SPINE AND ORTHOPEDIC PAIN CENTER, P.C. WINIFRED D. BRAGG, M.D.
SPINE AND ORTHOPEDIC PAIN CENTER, P.C. WINIFRED D. BRAGG, M.D. PATIENT INFORMATION Patient Name (Last, First, Middle Initial) Home Address Gender (M/F) Phone (Home) City State Zip code Phone (Work) Marital