PATIENT INTAKE QUESTIONNAIRE DR. LARRY TODD JR., D.O.

Transcription

1 OrthoNeuro For every motion in life. Joint Spine Sport Name: DOB Height Weight lbs. SS# Referring Physician Age Sex Reason For visit: PATIENT INTAKE QUESTIONNAIRE DR. LARRY TODD JR., D.O. Medical Problems: Please check below all the conditions that pertain to you heart disease brain tumor panic attacks high blood pressure meningitis depression high cholesterol encephalitis mental illness stroke headaches sleep disorder anemia seizure/epilepsy snoring aneurysm thyroid problems lung disease bleeding disorders sore throat bronchitis/asthma blood clots/phlebitis sinusitis tuberculosis skin disorder glaucoma mononucleosis ulcer/stomach disease kidney disease hepatitis A or B diabetes arthritis (ostco/rhcnmatoid) liver disease hypoglycemia cancer ear infection other (explain ) Surgeries and hospitalizations (year, hospital/city, nature of surgery/procedure) Medications: Allergies to medications: If you are a women age 65 or older Have you been screened (DXA scan) for osteoporosis since you turned 60 years old? Y N If yes, what was the result of the testing? Have you been prescribed medication to prevent or treat osteoporosis? Y N If yes, what medication are you taking? Patient's Name (please print) For information call

2 Social History: single married divorced widowed Children's Name(s) Age(s) Do you smoke? Y N If yes, packs per day for years Have you ever smoked? Y N If yes, when did you quit? How long did you smoke? Smokeless tobacco? Y N Do you drink alcohol? Y N If yes, beers per week ounces of liquor per week Have you ever drank alcohol? Y N glasses of wine per week Have you ever used recreational drugs? Y N If yes, list Last year of school completed Review of Systems: Please mark with a check if you would answer yes to any of the following questions. Do you have a fever? Do you have a skin rash? Have you gained 5 or more lbs. in the last 6 months? If so, how much? lbs. Have you lost 5 or more lbs. in the last 6 months? If so, how much? lbs. Are you intolerant of heat? Are you intolerant of cold? Do you sweat heavily at night? Do you have any skin lumps, cysts or lesions? If yes, explain Have you noticed any changes in your skin, teeth, hair or nails? Do you have eye pain, redness or inflammation? Are you experiencing blurry or double vision? Have you lost vision in one or both eyes? Do you experience dizziness or lightheadedness? Have you ever fainted, blacked out or passed out? Do you have difficulties with balance or unsteadiness? Do you have ear pain or fullness? Patient's name (please print)

3 Do you have hearing difficulties or ringing in your ears? Does your face ever become numb? Is your sense of smell or taste diminished? Are your teeth sensitive to hot food or drinks? Are your teeth sensitive to cold foods or drinks? Do you have bloody sinus discharge? Do you have sinus discharge that is mostly mucus? Do you have chest pain? Does your heart race? Does your heart skip beats? Do you become short of breath? Do your feet or ankles swell? Do you frequently cough up phlegm? Do you ever cough up blood? Do you have a persistent cough or wheeze? Do you have pain or discomfort in your abdomen? Has your appetite changed recently? Have you recently had nausea or vomiting? Do you suffer from constipation, diarrhea or excessive gas? Have you ever been jaundiced? Do you have burning or pain with urination? Do you have to urinate frequently? Do you get up at night to urinate? If so, how many times? Family History: Please check if any of the following pertain to your immediate family (brothers, sisters, mother or father). If yes, please indicate all applicable family members. heart disease cancer lung disease headaches arthritis stroke ulcer diabetes brain tumor Signature Physician Signature seizure or epilepsy hypoglycemia high blood pressure thyroid problems high cholesterol muscular disease spine problems panic attacks mental illness Med. Ass't. Use Only: BP:

4 Back Pain If work-related, DOI: Employer: Description of accident: Onset of back pain: Location (as described by pt.): Current pain rating (average): /10 At worst: /10 Distance comfortably walked: Provocative: Occupation: Last day of work: Palliative: Leg Pain Frequency of leg pain: Current pain rating (average): /10 At worst: /10 % of right leg pain % % of left leg pain % buttock: L R both thigh: L anterior posterior medial lateral R anterior posterior medial lateral leg: L anterior posterior medial lateral R anterior posterior medial lateral foot: L top bottom toes heel ankle R top bottom toes heel ankle Red Flags B & B changes Fever/chills Unexplained wt. loss Pain awakens from sleep Previous Pain Relief Efforts Effective % relief PT Y N Epidural Injections Y N NSAIDs Y N Narcotics Y N Diagnostic History X rays ( ) CT ( ) MRI ( ) EMG( ) Patient Signature: :

5 Patient's Name (please print) Physical Exam Template - Back Pain 1. Gait (antalgic, widened, unsteady) 2. Toe walk (SI) 3. Heel walk (L4, L5) 4. Flexion of back 5. Extension of back degrees 6. Patellar reflexes 7. Achilles reflexes 8. Ankle clonus (absent, 1 beat, 2 beats, sustained) 9. Dorsalis pedis pulses 10. Babinski If hip/si joint pain: 11. Extensor hallicus longus (L5) Patrick's/Fabere 12. Peroneals (S1) Gaenlen's sign 13. Tibialis anteriors (L4) Pelvic compression 14. Quadriceps (L4, L3, L2) Stinchfield's sign 15. Iliopsoas (L1, L2, L3) 16. SLR 17. Log rolling 18. Sensory in lower extremities Waddell signs 19. Long finger flexors (C8) 20. Intrinsics (T1) 21. Biceps, triceps and brachioradialis reflexes 22. Hoffman's sign 23. Skin markings 24. Affect 25. Alert and oriented x 3 Physician Signature: :

6 AUTHORIZATIONS Section 1: Financial Policy I have reviewed OrthoNeuro s Financial Policy and Authorizations (collectively, the Financial Policy ), hereby acknowledge my responsibilities set forth in the Financial Policy, and hereby make the authorizations set forth in the Financial Policy. Please initial: Section 2: Appointment of Personal Representative to Receive Protected Health Information You may rely upon your spouse, relatives or friends to be involved in your medical care. OrthoNeuro can Disclose your Protected Health Information to these people if you appoint them as your personal representatives. To appoint an individual as your personal representative, complete this section: I hereby appoint the following individual as my personal representative: Name: Relationship to me: I hereby authorize OrthoNeuro to Disclose the following Protected Health Information to my personal representative: All Protected Health Information OR One or more of these choices: Times of Appointments Test Results Prescriptions & Ancillary Equipment Copies of Medical Records Other I may revoke my appointment of a personal representative at any time in writing. I understand that revocation of my appointment will NOT affect any action OrthoNeuro took in reliance on my appointment before it received written notice of my revocation. Please initial: Section 3: Receipt of Notice of Privacy Practices I hereby acknowledge receiving a copy of OrthoNeuro s Notice of Privacy Practices that outlines my privacy rights and explains how OrthoNeuro is permitted to Use and Disclose my Protected Health Information. I should call OrthoNeuro s Privacy Officer at (614) if I have a question or concern about my privacy rights. Please initial: Section 4: Patient Information Race: Ethnicity: of Birth: Language: Social Security Number: Emergency Contact: Phone Number: By signing below, I am acknowledging that I have read and understand this form. Patient Name (please print) Patient Signature If applicable, Parent/Guardian Name If applicable, Parent/Guardian Signature (Please Print)