Patient Registration (Please complete all pages. Thank you.) PATIENT INFORMATION
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1 Patient Registration (Please complete all pages. Thank you.) PATIENT INFORMATION PATIENT NAME (Last, First, Middle Initial) ADDRESS ADDRESS SOCIAL SECURITY NUMBER DATE OF BIRTH CITY STATE ZIP HOME TELEPHONE NUMBER CELL TELEPHONE NUMBER WORK PHONE NUMBER MALE FEMALE (circle one) FAMILY PHYSICIAN MARTIAL STATUS OCCUPATION/EMPLOYER Would you like to join our list to receive news, updates and specials? Yes/No How did you hear about us? Check one. Doctor Advertisement Friend/Relative (who?) Other WHO IS FINANCIALLY RESPONSIBLE FOR TREATMENT? Myself My Spouse My Parent(s) INSURANCE INFORMATION Primary Insurance Company: Secondary Insurance Company: Please give your insurance card/cards to the receptionist so they can make a copy for your record. POLICY HOLDER S INFORMATION (If NOT the patient) NAME RELATIONSHIP TO PATIENT EMPLOYER ADDRESS (if different from above) DATE OF BIRTH CITY STATE ZIP HOME TELEPHONE (if different from above) EMERGENCY CONTACT NAME (Last, First, Middle Initial) RELATIONSHIP TO PATIENT ADDRESS CITY STATE ZIP TELEPHONE #
2 Patient History 1. Describe the current problem that brought you here? 2. When did your problem first begin? months ago or years ago. 3. Was your first episode of the problem related to a specific incident? Yes/No Please describe and specify date 4. Since that time is it: staying the same getting worse getting better. Why or How? 5. If pain is present rate pain on a 0-10 scale, 10 being the worst. Describe the nature of the pain (i.e. constant burning, intermittent ache) 6. Describe previous treatment/exercises 7. Activities/events that cause or aggravate your symptoms. Check/circle all that apply. Sitting greater than minutes Walking greater than minutes Standing greater than minutes Changing positions (i.e. sit to stand) Light activity (light housework) Vigorous activity/exercise (run/weight lift/jump) Sexual activity Other, please list With cough/sneezes/straining With laughing/yelling With lifting/bending With cold weather With triggers running water/key in door With nervousness/anxiety No activity affects the problem 8. What relieves your symptoms? 9. How has your lifestyle/quality of life been altered/changed because of this problem? Social activities (exclude physical activities), specify Diet/Fluid intake, specify_ Physical activity, specify_ Work, specify Other 10. What are your treatment goals/concerns? 11. Since the onset of your current symptoms have you had: Y/N Fever/Chills Y/N Unexplained weight change Y/N Dizziness or fainting Y/N Change in bowel or bladder functions Y/N Malaise (unexplained tiredness) 12. Bladder/Bowel Habits/Problems Y/N Trouble initiating urine stream Y/N Unexplained muscle weakness Y/N Night pain/sweats Y/N Numbness/ Tingling Other/describe Y/N Urinary intermittent/slow stream
3 Y/N Trouble emptying bladder Y/N Difficulty stopping urine stream Y/N Trouble emptying bladder completely 13. Do you have or have you had any of the following? Dizziness/ Vertigo Stroke Severe headaches Blurred Vision Double Vision Ringing in your ears Nausea Epilepsy Multiple Sclerosis Depression Chemical Dependency Fever Confusion Pain in Calves Muscle Pain Fatigue Skin Disorder Y/N Straining or pushing to empty bladder Y/N Dribbling after urination Y/N Constant urine leakage Now Past Now Past Diabetes Arthritis Osteoporosis High blood pressure Shortness of breath Asthma Chronic Bronchitis Irregular heartbeat Chest Pain Heart disease Heart Attack Pacemaker Congestive Heart Failure Peripheral Vascular Disease Thrombophlebitis Anemia Hemophilia Smoker How many Packs a day? Tuberculosis Hepatitis C Acquired Immune Deficiency/ HIV Hepatitis B Cancer Please list type Thyroid problems Kidney/ Bladder Problems Liver Problems Abdominal pain/discomfort Ulcer/ Colitis Hernia 14.If your family has a history of any of the above please list: 15. List any other information regarding your medical history not detailed above: 16. Have you fallen in the past 2 years? If so, how many times and approximately when did the fall(s) occur?
4 Pelvic Symptom Questionnaire Bladder/ Bowel Habits/ Problems Y/N Trouble initiating urine stream Y/N Urinary Intermittent/ slow stream Y/N Trouble emptying bladder Y/N Difficulty stopping the urine stream Y/N Straining or pushing to empty bladder Y/N Dribbling after urination Y/N Constant urine leakage Y/N Blood in urine Y/N Painful urination Y/N Trouble feeling bladder urge/fullness Y/N Current Laxative use Y/N Trouble feeling bowl/urge/fullness Y/N Constipation/straining Y/N Trouble holding back gas/ feces Y/N Recurrent bladder infections Other/describe 1. Frequency of urination: awake hour s times per day, sleep hours times per night 2. When you have a normal urge to urinate, how long can you delay before you have to go to the toilet? minutes, hours, not at all. 3. The usual amount of urine passed is: small, medium, large. 4. Frequency of bowel movements times per day, times per week, Or. 5. When you have an urge to have a bowel movement, how long can you delay before you have to go to the toilet? minutes, hours, not at all. 6. If constipation is present describe management techniques 7. Average fluid intake (one glass is 8 oz or one cup) glasses per day. Of this total how many glasses are caffeinated? glasses per day. 8. Rate a feeling of organ falling out / prolapse or pelvic heaviness/ pressure: None present Times per month (specify if related to activity or your period) With standing for minutes or hours. With exertion or straining Other Skip questions if no leakage/incontinence 9. Bladder leakage number of episodes Times per day Times per week Times per month Only with physical exertion/cough 10. On average, how much urine do you leak? Just a few drops Wets underwear Wets outerwear Bowel leakage number of episodes Times per day Times per week Times per month Only with exertion/strong urge How much stool do you lose? Stool staining Small amount in underwear Complete emptying Wets the floor 11. What form of protection do you wear? (Please complete only one) None Minimal protection (Tissue paper/paper towel/pantishields) Moderate protection (absorbent product, maxipad) Maximum protection (Specialty product/diaper) Other
5 On average, how many pads/protection changes are required in 24 hours? # of pads **I certify that the information I have provided is complete and true to the best of my knowledge. I understand that I am financially responsible for all charges at the time services are rendered. I further understand that ABove Physical Therapy, LLC will provide me with the appropriate documentation to seek re-imbursement from my insurance provider. I acknowledge that ABove Physical Therapy is not responsible for the re-imbursement of these services. I have read the foregoing and I understand it. Any questions that have arisen or occurred to me have been answered to my satisfaction. Patient or Patient Representative Signature Witness Date Date
Patient History. 6. Rate the severity of this problem from 0-10 /10 7. Describe previous treatment/exercises
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Patient History. 2. Rate the severity of this problem from 0-10 with 0 being no problem and 10 being the worst
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New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:
Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State
Patient information Today s Date Patient s Name D.O.B Street Address Apt. No. City / State / Zip Code Home Phone # Work Phone # Social Security # DL # State Sex Female Male Marital Status Single Married
New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors