PATIENT NAME: DATE: ADDRESS: CITY: STATE: ZIP: Primary PHONE: SOCIAL SECURITY #: AGE: DOB / / SEX: M F HEIGHT: WEIGHT:
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1 PATIENT NAME: DATE: ADDRESS: CITY: STATE: ZIP: Primary PHONE: SOCIAL SECURITY #: AGE: DOB / / SEX: M F HEIGHT: WEIGHT: On the diagram below, shade the area and rate the severity from 0 to 10 (0=none 10=most severe) of your present pain/symptoms, describing each as A=achy P=pressure D=dull S=sharp Th=throbbing B=burning T=tight Date when your pain/symptoms originally, first began: Date of this current episode: What caused it? When is the pain/symptom present? Constantly Frequently Infrequently How often do you have it? 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% of the day. Do you currently experience any of these sounds/feelings in your jaw: (R-Right or L-Left): Clicking R L Popping R L Grating sound R L Pain R L Sticking/locking R L How long have you had these sounds/feelings in your jaw? Is there a certain spot that triggers your pain/symptom? Y N Where? What time of day is it worse? morning afternoon evening middle of night What makes it feel better? What makes it feel worse? What do the symptoms keep you from doing? Describe your daily stress level: High Moderate Mild None 1/8
2 Circle YES or NO under the heading on the left, and if indicated, under the PAST heading on the right. Circle, when applicable, which choice in italics best describes your answer. R=right, L=left Wake up with pain/tightness in cheeks, jaw, temples Wake up with teeth sensitivity to temperature Wake up with stiff jaw, decreased range of comfortable opening Wake up irritable, grouchy, anxiety Symptoms increase when eating or chewing Prescribed a mouth guard, night guard, splint, appliance Still using it? Worn it for how long? Bite on nails, cuticles, lip, cheeks, objects, gum, sunflower seeds Leaning jaw/head on palm of hand Pushing tongue against front teeth or roof of mouth Use teeth as tool/scissors to tear packaging, thread Sense of an altered bite, altered jaw posture or altered jaw function during chewing, speech or other mouth movement Play a wind instrument, talk continuously, or sing more than 5 hrs/week Jaw Clench or grind teeth when: (circle) sleep driving using computer/device at other times What % of the day are your teeth touching? % PAST R L Jaw Pain R L Pain in cheek muscles R L Jaw joint noise R L Limited opening/movement? R L Jaw sticking/locking/dislocation R L Uncontrollable jaw and/or tongue movements R L Inability to open mouth smoothly? Mouth stuck or locked Open Closed Unable to open mouth wide?. When: Unable to close your mouth? When: R L Painful opening/closing of mouth R L Changes in bite position R L Stiff/tight or tired jaw R L Jaw injury or dislocation R L Braces and or neck/headgear How long? 1 year 2 years 3 years 4 years 2/8
3 PAST R L Facial pain/tightness? R L Headaches AM or PM Type: sinus migraine cluster ocular stress frontal R L Hit in the face or head R L Shooting pain up back fo head R L Hair and/or scalp painful to touch Pain, looseness, sensitivity Which ones? Clench teeth during day or night Grinding teeth during day or night R L One side of teeth/molars touch before the other Sensitivity with hot/cold beverages Swelling over jaw joint Swelling inside mouth or throat R L Ear pain, ache, no infection R L Stuffiness in ears R L Clogged, dampening sound R L Itchy ears R L Hissing/buzzing/ringing R L Vertigo/Dizziness R L Pain/pressure above, below, behind eyes R L Bloodshot eyes R L Blurred vision R L Difficulty moving eyes R L Watering of eyes R L Drooping of eyelids Difficulty Swallowing R L Hoarse or one sided sore throat Laryngitis, voice irregularities Frequent coughing/clearing throat R L Feeling of foreign object in throat PAST Symptoms increase bending forward Increase when swallowing R L Increase when turning head Increase when laying down Increase after reading/straining eyes Dizziness balance problems vertigo R L Numbness or tingling in hands Symptoms in head, neck, and shoulder 3/8
4 increased following speech, chewing, yawning, etc. R L Do you have cheek pain R L Do you have temple pain R L Do you have neck pain R L Do you have low back pain R L Do you have tailbone pain R L An injury/fall on tailbone (example: snowboarding, horseback riding, missed chair, sat down hard) PAST R L History of whiplash, neck injury R L Surgery to jaw, neck or head? When: Why: R L Tired, sore muscles constantly: neck shoulders mid back low back R L Hand/finger numbness/pain R L Decreased range of motion in neck R L Decreased range of motion in low back Chronic fatigue Movement difficulties of eyes, tongue, facial muscles, or making an expression? R L Numbness or tingling of face? R L Bell s Palsy R L Trigeminal Neuralgia/Tic Douloureux R L Shingles on head or neck Auto Accidents When: Treatment received Slip and fall, or other incident? When: Treatment received Injury to: head, neck, low back, shoulder, jaw When? Treatment received Constant waking up in middle of night Do you breathe with an open mouth Do you have sleep apnea Do you use a CPAP type machine or appliance Do you sleep well at night Does your partner tell you that you grind your teeth at night Do you snore nightly Crave sweets, feel faint when hungry, sleepy right after eating, irritable when hungry PAST 4/8
5 Disequilibrium/Discoordination Mental Confusion Irritability Fever Nasal Congestion or stuffiness Recurrent swelling or tenderness of joints other than in your jaw joint Morning stiffness in your body, other than your jaw Muscle tenderness in your body other than in your face/head/neck for more than 50% of the day? Where?_ Do you have suicidal thoughts or thoughts of hurting others? How often are you tense, aggravated, stressed, or frustrated during a usual day? always half the day seldom never How often do you feel depressed, sad, blue, or listless during a usual day? always half the day seldom never Describe any other symptoms you associate with the problem: What treatment do you think is needed for your problem? Is there anything else you think we should know about your problem?_ Have you ever been treated for this before? When? Duration: By whom? What was the treatment? Outcome? I certify that all information in these 8 pages is complete and accurate to the best of my knowledge. I agree to notify this doctor immediately whenever I have changes in my health condition in the future. Patient s Signature: Date: 8 MINOR CONSENT: I,, being the legal guardian of, authorize to seek, obtain and consent to, for as deemed necessary by Dr. Kimberly Bensen, DC. This authorization is for the time period when my child is in care of Dr. Bensen, from / /20 until revoked by me. Parent/Guardian Information: Full Name: Phone Number: Address: Other Parent/Guardian Information: (if necessary) Full Name: Phone Number: Address: 5/8
6 If you have ever had a listed symptom in the PAST, please check that symptom in the Past Column. If you are presently troubled by a particular symptom, check that symptom in the Column. KLEDGE OF THESE CONDITIONS MAY INFLUENCE THE TYPE OF TREATMENT/THERAPY YOU RECEIVE. PAST CONDITION PAST CONDITION allergies (to what): asthma emphysema COPD (chronic obstructive pulmonary disease) chronic cough aortic aneurysm high blood pressure angina chronic sinusitis heart attack date: hand pain R or L stroke date: wrist pain R or L chest pains upper arm/elbow pain R or L Blood disorders ankle/foot pain R or L upper leg/hip pain R or L cancer date: type: low leg/knee pain R or L tumor type: ankle/foot pain R or L epilepsy blood sugar issues:diabetes, hypoglycemina, hyperglycemia osteoarthritis, degenerative joint disease, disc problems rheumatoid arthritis Ehlers Danlos, Marfans, Hypermobility disorder loss of appetite endometriosis or PMS irregular menstrual flow breast soreness or lumps pregnancy #births: bladder infection anorexia/bulimia kidney disorders type: 6/8
7 PAST CONDITION PAST CONDITION colitis depression, anxieties, anxiousness dermatitis/eczema/rash abnormal weight gain/ loss chronic sinusitis general fatigue irregular menstrual flow breast soreness or lumps endometriosis or PMS loss of bladder control painful urination frequent urination irritable colon HIV/AIDS drug or alcohol dependence ALL MEDICATIONS List: HOSPITALIZATIONS /SURGERIES FAMILY HISTORY abdominal pain Rheumatoid Arthritis constipation/irregular bowel habits difficulty in swallowing heartburn or indegestion pregnancy #births: birth control pills hepatitis type: high blood pressure heart problems Ehlers Danlos, Marfans, hypermobility disorders cancer, type: chronic back problems headaches, migraines TMJD, Jaw problems 7/8
8 Describe ANY ADDITIONAL Present Complaints, Other Than TMJ Please check all your answers and fill in the blanks where appropriate. Date problem began: / / Describe your problem and how it began: Mark and rate the severity from 0 to 10 (0=none 10=most severe) of your pain/symptoms on the body picture above where the additional problem(s) is/are: How often are your symptoms present? (circle corresponding) Constantly Frequently Occasionally Intermittent Describe your current pain/symptoms: Sharp Stabbing Throbbing Achy Dull Soreness Weakness Numbness Shooting Burning Tingling Other: Since it began, is your problem: Improving Getting Worse No Change What makes the problem better? Walking Lying Down Standing Sitting Movements Exercise Inactivity/Rest Other What makes the problem worse? Walking Lying Down Standing Sitting Movements Exercise inactivity/rest Other Can you perform your daily activities? Yes Yes with help Not at all Describe your job requirements: Heavy Labor Light Labor Mainly Sitting Mainly Standing Can you perform your work activities? Yes, all activities Only some Not at all Describe your stress level: High Moderate Mild None What treatment have you had for this condition in the past? Surgery Medications Injections Physical Therapy Chiropractic Adjustments What tests have you had for this condition: X-rays MRI Scans Other: Dates Taken: 8/8
PATIENT NAME: DATE: ADDRESS: CITY: STATE: ZIP: Primary PHONE: SOCIAL SECURITY #: AGE: DOB / / SEX: M F HEIGHT: WEIGHT:
1 PATIENT NAME: DATE: EMAIL ADDRESS: @ ADDRESS: CITY: STATE: ZIP: Primary PHONE: SOCIAL SECURITY #: AGE: DOB / / SEX: M F HEIGHT: WEIGHT: On the diagram below, shade the area and rate the severity from
Patient Intake Dr. Kimberly Bensen For TMJ Symptoms
PATIENT NAME: DATE: EMAIL ADDRESS: @ ADDRESS: CITY: STATE: ZIP: Primary PHONE: SOCIAL SECURITY #: AGE: DOB / / SEX: M F HEIGHT: WEIGHT: On the diagram below, place a number (none 0 to 10 worse), that corresponds
PATIENT NAME: DATE: Phone#: On the diagram below, please shade the areas of pain:
PATIENT INTAKE: TMJ HISTORY PATIENT NAME: DATE: EMAIL: Phone#: On the diagram below, please shade the areas of pain: Date your symptoms began: What symptoms are you experiencing in your jaw? Right or Left:
PERSONAL INJURY QUESTIONNAIRE
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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Employed? Yes No Employer Name. Occupation. Problem Onset Frequency Severity E.g. Headaches June times per week Mild / Moderate / Severe
PLEASE NOTE: This file must be saved to your desktop before and after completing! PATIENT INFORMATION Date First Name SSN Sex Marital Status Middle Name Birth Date Last Name Height Spouse Name Address
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:
New Patient Intake Form. Patient s Full Name. Male Female Age: Date of Birth: / / Mailing Address: City: State: Zip:
New Patient Intake Form Date: / / Patient s Full Name E-Mail: Home Phone: Cell: Male Female Age: Date of Birth: / / Social Security # - - Mailing Address: City: State: Zip: Married Single Widowed Separated
Eastern Shore MediCann Clinic, LLC
Eastern Shore MediCann Clinic, LLC New Patient Medical History and Intake Form Medical Marijuana Certification Name Date of Birth Social Security Number Gender: Male Female Address: Street: City: State
Orthodontic Questionnaire. Please tell us why you have presented for evaluation and possible treatment. Dental History
Orthodontic Consultation file:///c:/programdata/nierman/dentalwriternet/reports/out.html Version: ORTHOQ Orthodontic Questionnaire OFFICE USE Patient ID: NAME: -' Crowding ' Overbite CURRENT DATE: / /
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
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.
NEW PATIENT INFORMATION
OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
Carriage House Chiropractic and Acupuncture
Chiropractic Patient History Questionnaire Date: Name: Date of birth: Address: City: St: Zip: Phone: (home) (cell) (work) May we send appointment reminders to you via text messages on your cell phone Email:
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Debra Joan Wood, Lic Ac, MAcOM Acupuncture and Herbs Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. If there
Last First MI. Full Mailing Address:
BridgeMill Family Healthcare, LLC Date Patient Information Name: Full Mailing Address: Last First MI Phone# (Mobile) (Home) (Work) Email Address Date of Birth: Sex: Male Female SS#: Marital Status: Single
COOK CHIROPRACTIC CLINIC 1715 S MAIN ST KANNAPOLIS NC FX:
COOK CHIROPRACTIC CLINIC 1715 S MAIN ST KANNAPOLIS NC 28081 704-938-7111 FX:704-932-4066 Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address Line
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
Whom may we thank for referring you to this office Today s Date: PATIENT DEMOGRAPHICS? HRN: Name: Birth Date: Age: Male Female Address: City: State: Zip: E mail Address: Home Phone: Mobile Phone: Marital
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:
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
Patient History Questionnaire
Patient History Questionnaire Date: Referred By: Name: DOB: Age: SSN: Home Telephone: Cell Phone: E-mail: Blood Pressure: Weight: Height: (Circle) R or L Handed (Check) Medication List Attached Emergency
Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should