DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)
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- Sara Morrison
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1 1275 Olentangy River Rd. Ste 120 Columbus, Ohio Telephone (614) Fax: (614) Dr. David B. Kaplansky Dr. Randall Contento PATIENT Dr. INFORMATION Garrett Kalmar FORM E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614) DATE: / / PATIENT NAME: DATE OF BIRTH: / / AGE: SEX: M F Last First MI Home Address: SSN CITY/STATE: ZIP: HOME PHONE #: ( ) - MAY WE LEAVE A MESSAGE? YES NO ALTERNATE PHONE #: ( ) - MAY WE LEAVE A MESSAGE? YES NO MAY WE LEAVE A MESSAGE? YES NO PRIMARY LANGUAGE: ETHNICITY DO YOU HAVE A LEGAL GUARDIAN OR HEALTHCARE POWER OF ATTORNEY? YES NO IF YES, NAME: RELATIONSHIP: PHONE #: ( ) - EMERGENCY CONTACT: RELATIONSHIP: PHONE #: ( ) - PRIMARY CARE DOCTOR: PHONE #: WHO (EX: NAME OF DOCTOR, FRIEND, INTERNET) REFERRED YOU TO US? PHARMACY: ZIP PHONE #: ( ) - IS THERE A FAMILY MEMBER OR OTHER PERSON YOU WOULD LIKE FOR US TO SHARE YOUR MEDICAL INFORMATION? YES NAME(S) NO WHO IS RESPONSIBLE FOR PAYMENT? RELATIONSHIP TO PATIENT? ADDRESS: CITY/STATE: ZIP: PHONE #: ( ) - INSURANCE INFORMATION PRIMARY INSURANCE COMPANY NAME ADDRESS: CITY/STATE: ZIP: PHONE #: ( ) - INSURED NAME: DATE OF BIRTH EMPLOYER CONTRACT # GROUP # SECONDARY INSURANCE COMPANY NAME ADDRESS: CITY/STATE: ZIP: PHONE #: ( ) - INSURED NAME: DATE OF BIRTH EMPLOYER CONTRACT # GROUP # 1
2 SOCIAL HISTORY MARITAL STATUS:! SINGLE! MARRIED! PARTNERED! SEPARATED! DIVORCED! WIDOWED USE OF ALCOHOL:! NEVER! NO LONGER USE! HISTORY OF ALCOHOL ABUSE! NUMBER OF DRINKS PER WEEK - USE OF TOBACCO:! NEVER! QUIT HOW LONG AGO?! SMOKE PACKS/DAY FOR YEARS USE OF RECREATIONAL DRUGS:! NEVER! QUIT HOW LONG AGO? TYPE EMPLOYER: OCCUPATION: HOW MUCH ARE YOU ON YOUR FEET AT WORK?! 10%! 25%! 50%! 75%! 100% DO OTHERS DEPEND UPON YOU FOR THEIR CARE?! CHILDREN AGE! ELDERLY OR DISABLED FAMILY MEMBER! OTHER EXERCISE:! NEVER! RARE! OCCASIONAL! WEEKLY! SEVERAL TIMES A WEEK! DAILY TYPES OF EXERCISE: HEIGHT FEET INCHES WEIGHT POUNDS SHOE SIZE FAMILY HISTORY DO YOU HAVE A FAMILY HISTORY OF: FAMILY MEMBER (EXAMPLE: MOTHER, FATHER, SISTER)! DIABETES! CANCER! HEART DISEASE! HIGH BLOOD PRESSURE! STROKE! RHEUMATOID ARTHRITIS! OTHER PLEASE LIST ALL PRIOR SURGERIES: TYPE OF SURGERY DATE 2
3 PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS): NAME DOSE REASON? YOUR MEDICAL HISTORY ALLERGIES:! NONE KNOWN! MEDICATIONS (LIST BELOW)! ANESTHESIA! FOODS! TAPE! LATEX! SHELLFISH! IODINE! OTHER Medical Problems: Which of the following conditions are you currently being treated or have been treated for in the past (please check) Heart disease / Murmur / Angina Shortness of breathe Eye disorder / Glaucoma Diabetes High cholesterol Asthma Seizures Kidney / Bladder problems High blood pressure Lung problems / cough/ COPD Stroke Liver problems / Hepatitis Low blood pressure Sinus problems Headaches / Migraines Arthritis (rheumatoid or osteoarthritis) Heartburn (reflux) Seasonal allergies Neurological problems Cancer Anemia or blood problems Tonsillitis Depression / Anxiety Ulcers/colitis Hepatitis Swollen ankles Ear problems Psychiatric care Thyroid problems Infectious Disease (HIV, AID s) Others/any additional information regarding your medical conditions 3
4 Review of Systems: circle or write in any symptoms that apply to you currently Constitutional: (nausea, recent illness, fever, chills, night sweats, anorexia, fatigue, insomnia, weight gain/loss) Eyes (visual changes, cataract, glaucoma, discharge, injuries, glasses or contacts) Head, Ears, Nose, Throat (head injuries, headache, dizziness, difficulty with hearing, pain, discharge, ear infections, ventilation tubes, sinus congestion, sore throat, discharge: watery or purulent, difficulty in breathing through nose, bloody nose, sore throat or tongue, difficulty in swallowing, dental defects, swollen glands, masses) Lungs(shortness of breath, ability to keep up with peers, cough, heezing) Heart (cyanosis, arrhythmia, edema, heart murmurs or "heart trouble," pain over heart), Gastrointestinal (nausea, vomiting, abnormal bowel movements, abdominal pain, jaundice, reflux) Genitourinary (dysuria, hematuria, urethral or vaginal discharge, sores, pain, venereal disease, pregnant, abortions) Musculoskeletal ( back pain, stiffness, swelling, muscle weakness, deformities, difficulty in moving extremities or in walking, joint pains and swelling, muscle pains or cramps) Skin (skin cancer, rashes, calluses, nail changes, psoriasis, cellulitis, skin color change, abnormal moles, easy bruising or bleeding) Neurologic (headaches, fainting, dizziness, seizures, numbness, tremors) Psychiatric (nervousness/anxiety, drug use or abuse, psycosis, suicidality) Endocrine: Hypo/Hyper-thyroid, hyperglycemic/diabetes CURRENT PROBLEM (CHIEF COMPLAINT) WHAT SPECIFIC PROBLEM BRINGS YOU TO OUR OFFICE TODAY? WHERE IS THE PAIN/PROBLEM LOCATED? PLEASE MARK ON THE PICTURES BELOW. LEFT FOOT RIGHT FOOT TOP BOTTOM BOTTOM BOTTOM OF TOP INSIDE OUTSIDE INSIDE OUTSIDE HOW LONG AGO DID THIS PROBLEM FIRST START? DAYS / WEEKS / MONTHS / YEARS 4
5 DID YOUR PAIN OR PROBLEM:! BEGIN ALL OF A SUDDEN! GRADUALLY DEVELOP OVER TIME HOW WOULD YOU DESCRIBE YOUR PAIN?! NO PAIN! SHARP! DULL! ACHING! BURNING! RADIATING! ITCHING! STABBING! OTHER HOW WOULD YOU DESCRIBE YOUR PAIN? (PLEASE CIRCLE) NO PAIN MILD PAIN MODERATE PAIN SEVERE PAIN SINCE THE TIME YOUR PAIN OR PROBLEM BEGAN, HAS IT:! STAYED THE SAME! BECOME WORSE! IMPROVED WHAT MAKES YOUR PAIN OR PROBLEM FEEL WORSE?! WALKING! STANDING! DAILY ACTIVITIES! RESTING! DRESS SHOES! HIGH HEELS! FLAT SHOES! ANY CLOSED TOE SHOE! RUNNING! OTHER WHAT MAKES YOUR PAIN OR PROBLEM FEEL BETTER? WHAT TREATMENTS HAVE YOU HAD FOR THIS PROBLEM? HOW HAS THIS PROBLEM AFFECTED YOUR LIFESTYLE OR ABILITY TO WORK? WAS THIS PROBLEM CAUSED BY AN INJURY?! YES (DESCRIBE BELOW)! NO TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL STATUS. DATE SIGN NAME OF PATIENT, PARENT OR GUARDIAN REVIEWED BY UPDATED
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