Thank you for choosing Holy Cross Outpatient Rehabilitation
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- Clarence Lester
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1 Thank you for choosing Holy Cross Outpatient Rehabilitation Please complete the attached paperwork prior to your arrival. Ensure you know which facility you are scheduled for. Please arrive 30 minutes prior to your scheduled appointment time to complete registration. If you have any questions please contact the facility 3 (1) Holy Cross Main Hospital PT/OT/Speech 4725 N Federal Highway F: Corner of Commercial Blvd 4 (2) HCMG Orthopedic Institute Holy Cross HealthPlex - PT/OT/Hand 5597 North Dixie Highway F: Between Commercial & Cypress Creek 2 1 (2) Women s Health Rehab Dorothy Mangurian Comprehensive Women s Center - PT 1000 NE 56 th Street F: Off Dixie north of Commercial Blvd (3) HCMG Ortho Institute West Boca PT/OT/Hand 9970 Central Park Blvd #400A Boca Raton F: North of Palmetto (4) West Boca Raton Urgent Care PT State Road 7 (441) Boca Raton F: (5) HCMG Rio Vista PT 1309 S Federal Highway F: South of Davie Blvd, N of I-595 Holy Cross Home Health (1) Zachariah Wellness Pavilion
2 Name: Date: Date of onset of: Injury Problem Surgery State your main reason for therapy: Do you now have, or have you ever had any of the following? High Blood Pressure... Yes No Pacemaker... Yes No Dizziness/Fainting... Yes No Osteoporosis... Yes No Cancer... Yes No Bowel/Bladder Problems... Yes No Kidney Problems... Yes No Stroke/Mini Stroke... Yes No Shortness of Breath... Yes No Heart Problems... Yes No Diabetes... Yes No Seizures... Yes No Fractures... Yes No Circulatory Problems... Yes No Recent Weight Change... Yes No Swallowing Problems... Yes No H/O Falls... Yes No Hip Replacement... Yes No Knee Replacement... Yes No Other... Yes No If YES to any of the above, please explain: Please list any other significant medical diagnoses or conditions: Please list any previous surgical, operative or invasive procedures that you have had: Please list any medications including long term, current, over-the-counter or herbal preparations that you are currently taking: Please describe any known adverse and allergic drug reactions: Is this problem related to a motor vehicle accident? Yes No If YES, when? Have you had this problem before? Yes No If YES, when? If YES, did you receive therapy for this problem? Yes No If YES, what treatment helped you? Has this problem limited your ability to perform everyday task? Yes No If YES, what are they? What are your goals for therapy? Be specific: FORM # /07/07 Page 1 of 1 PATIENT LABEL PATIENT INFORMATION REHABILITATION SERVICES
3 pain ScREEn 1. Do you have pain now? Yes No 2. If no, have you had pain in the last 24 hours or past few days, weeks or months? Yes No If the answer is no to both questions, STOp now! if the answer is YES to either question, continue below: 3. Is the pain you are experiencing of related to your current reason for therapy? Yes No If the answer to question #3 is YES, complete the INITIAL PAIN ASSESSMENT. initial pain assessment Location 1 Location 2 Location 3 Location 4 Location: Where do you have pain? Quality: What does your pain feel like for each location? (throbbing, tender shooting, stabbing, sharp, cramping, burning, aching, heavy, etc.) intensity: On a scale of 0-10 with 0 being no pain and 10 being the worst pain ever, Rate your pain as it feels now. Rate your pain at its best: (0-10) Rate your pain at its worst: (0-10) What is your goal for pain intensity? Time/Frequency: When did the pain start? Is the pain constant (always there) or intermittent (comes and goes)? What positions, situations help alleviate (ease) your pain? What activities or situations aggravate or makes your pain worse? What alternative therapies have you tried? none Cold Heat Massage Other: What works well? Works poorly? all of this information has been reviewed with the patient and/or family: Yes Signature of Person Completing Form Staff Signature Date Date
4 1 Name: Date: / / Score: This questionnaire is designed to help your Physical Therapist understand how much your neck pain has affected your ability to manage in everyday life. Please answer each section and mark only ONE BOX which best applies to you at this moment. PAIN INTENSITY I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is worst imaginable at the moment PERSONAL CARE I would not have to change my way of washing or dressing to avoid pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help, but manage most of my personal care I need help every day in most aspects of self-care I do not get dressed. I wash with difficulty and stay in bed LIFTING I can lift heavy weights without extra pain I can lift heavy weights but it causes extra pain Pain prevents me from lifting heavy weights off the floor but I can if they are conveniently positioned, like on a table Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can lift very light weights I cannot lift or carry anything at all READING I can read as much as I want with no pain in my neck I can read as much as I want with slight pain in my neck I can read as much as I want with moderate pain in my neck I cannot read as much as I want because of moderate pain in my neck I cannot read as much as I want because of severe pain in my neck I cannot read at all
5 2 HEADACHES I have no headaches at all I have slight headaches which come infrequently I have moderate headaches which come frequently I have moderate headaches which come infrequently I have severe headaches which come frequently I have headaches almost all the time DRIVING I can drive my car without neck pain I can drive my car as long as I want with slight pain in my neck I can drive my car as long as I want with moderate pain in my neck I cannot drive my car as long as I want because of moderate pain in my neck I can hardly drive because of severe pain in my neck I cannot drive my car at all. CONCENTRATION I can concentrate fully with no difficulty I can concentrate fully with slight difficulty I have a fair degree of difficulty concentrating I have a lot of difficulty concentrating I have a great deal of concentrating I cannot concentrate at all SLEEPING I have no trouble sleeping at all My sleep is slightly disturbed (less than 1 hour) My sleep is mildly disturbed (1-2 hours) My sleep is moderately disturbed (2-3 hours) My sleep is greatly disturbed (3-5 hours) My sleep is completely disturbed (5-7 hours) WORK I can do as much work as I want to I can only do my usual work, but no more I can do most of my usual work, but no more I cannot do my usual work I can hardly do any work at all I cannot do any work at all RECREATION I am able to engage in all recreational activities with no pain in my neck at all I am able to engage in all recreational activities with some pain in my neck I am able to engage in most, but not all recreational activities because of pain in my neck I am able to engage in a few of my usual activities because of my neck pain I can hardly do any recreational activities because of my neck I cannot do any recreational activities at all
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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
MICHIGAN INTERVENTIONAL PAIN ASSOCIATES
MICHIGAN INTERVENTIONAL PAIN ASSOCIATES Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and REPORTS of any X- rays, MRI or
New Patient Intake Form
New Patient Intake Form Please complete information below Name: DOB Age Male Female Referring Physician FAX Address Phone _ Primary Care Physician FAX Address Phone Is this a work related problem? If yes,
Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
Name: Age: Date: Accompanied by Relationship E-mail: @ MEDICAL BACKGROUND INFORMATION Please name the professionals that you have seen for this condition: Name Specialty Town Phone Who is your primary
CHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
List anything that caused/contributed to your problem(s) Is this new or Have you ever had these issues before? Yes No if yes, please explain
Name (Please Print)_ Date / / COMPLETE THESE DIAGRAMS Please list your areas of pain and then rate your pain. MARKING AREAS OF PAIN Zero=No Pain 0 1 2 3 4 5 6 7 8 9 10 10 =Unbearable 1. Rate 0-10 Onset
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
Patient Name: Cell Phone Home Phone Work Phone. Address City State Zip Address
Patient Name: Date Cell Phone Home Phone Work Phone Address City State Zip Email Address Sex M F Marital Status M S D W Date of Birth Age Social Security Number Occupation Employer Referred by Have you
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM Last Name: First Name: Middle: Home Phone: Other Contact: Other Contact: DOB: Age: Sex: Name of Referring Physician: Phone: Fax: Address: City: State: Zip: Name
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Phone ( ) Age Birth Date Sex S.S.N. Employer Address Did you report this to YOUR Car Insurance? Yes No (Circle One) Your Car Insurance Co. is Claim # Claims Adjuster
Name (First, Middle initial, Last): Mailing Address: Home phone: Cell Gender identification: M F Birthdate: Age: Birthplace:
General Information Name (First, Middle initial, Last): Mailing Address: Home phone: Cell Email Gender identification: M F Birthdate: Age: Birthplace: Nationality: Religion: Marital Status: Ages of children
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT Patient (First) (Middle) (Last) Address City State Zip E-mail address Home Phone # Cell Phone # Would you like an appointment reminder? Text( ) Call(
Name Date of Birth Today s Date
SWEDISH PAIN SERVICES: Initial Visit Questionnaire Name Date of Birth Today s Date We realize that some of the questions might not address your exact situation but please answer them to your best ability.