NEUROPATHY CLIENT HISTORY AND LIFESTYLE INTAKE
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- Buddy Hamilton
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1 NEUROPATHY CLIENT HISTORY AND LIFESTYLE INTAKE In order for us to completely evaluate your health status, please fill out the following pages. Be as thorough as possible. This allows us to assess your neurological and structural imbalances. Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Preferred phone number to call: Home Work Cell Phone May we leave a message? Y or N Date of Birth: / / Age: Spouse s Name Occupation (Current or Previous): Retired: Y or N Were you exposed to any chemicals in your past employment? Yes or No HEALTH HISTORY Allergies Are you allergic to any medications or drugs? Y N If yes, list names and type of reaction. (Example: penicillin rash) Have you ever been tested for food allergies? Y N Do you have any food allergies (i.e., lactose, gluten, nuts)? Y N If yes, what foods? Do any foods bother you? Y N (Example: tomatoes reflux). If yes, what foods? Do you have any environmental allergies? (Example: Dust, ragweed, animals)? Y N Do you have any seasonal allergies? Y N Please list all you can think of Diagnoses List any diagnosis you have had (Example: high blood pressure, hypothyroid, high cholesterol, diabetes, sleep apnea, neuropathy, depression, etc.) Blood Sugar Readings (if applicable) What was your lowest reading in the past 3 months? What was your highest reading in the past 3 months? What was your blood sugar level today? What was your last Hemoglobin A1C level? Date Checked: 2014 Dr. Keith S. Ungar Page 1
2 Current Medications (prescribed and over-the-counter) please complete separate sheet on last page. Do you think medications are helping? Y N Are you having any side effects? Y N Explain: Current Supplements (Vitamins) please complete separate sheet on last page Surgery Type of Surgery Date Reason Hospitalizations Date Hospital How long? Reason Example: 1/1/13 Cleve. Clinic 2 days _Gall Bladder Family History (If unknown, write unknown ). Family member Living? How old? List health conditions they had in their life (i.e. cancer, thyroid, heart attack, stroke, etc.) Mom Y N Dad Y N Mat. Grandmother Y N Pat. Grandmother Y N Mat. Grandfather Y N Pat. Grandfather Y N Sibling Y N Sibling Y N Sibling Y N Kids Name Age Health Status Living with you? Y N Y N Y N Y N Y N 2014 Dr. Keith S. Ungar Page 2
3 Review of Systems (Please check all that apply) Foot Pain Diabetes Spinal Stenosis Cancer Pinched Nerve Hand Pain High Cholesterol Degenerative Discs Chemotherapy Poor Circulation Low Back Pain High Blood Pressure Vascular Problems Arthritis in Hands Joint Replacements Neck Pain Pacemaker/Defibrillator Leg Pain Arthritis in Feet Foot Surgery Foot Numbness Herniated Disc Plantar Fasciitis Implanted Cord/Bladder Stimulator Poor wound healing Hand Numbness Bulging Disc Morton s Neuroma Sciatica Excessive thirst or urination Thyroid 2014 Dr. Keith S. Ungar Page 3
4 Present Health Conditions In order of importance, list the health problems you are most interested in getting corrected, and how long you have noticed these problems: 1) Length of Time: 2) Length of Time: 3) Length of Time: 4) Length of Time: 5) Length of Time: How would you describe your neuropathy symptoms? Please check all that apply. Then grade the level of discomfort on a scale of With 1 being the best and 10 being the worse. Aching Pain Numbness Hot sensation Cramping Stabbing Pain Tingling Throbbing Pain Swelling Sharp Pain Dead Feeling Burning Tiredness Heavy Feeling Cold Hands/Feet Electric Shocks Pins and Needles List anything that makes your condition worse: List anything that makes your condition better: 2014 Dr. Keith S. Ungar Page 4
5 Have your symptoms: Improved Worsened Stayed the Same Is there a certain time of day any of these problems are better or worse? Is your balance/walking ability affected? Y N If yes, please describe: Put a check mark by the things you have used for these problems: Gabapentin Neurontin Lyrica Cymbalta Physical Therapy Pain Medications Alleve Tylenol Ibuprofen Motrin Chiropractic Massage Therapy Injections Creams on Hands/Feet Other Medications or Treatments: What do you think is causing your problem?: How would you rate your overall symptoms in the last week? (On a scale of 0-10.With 0 being no pain or discomfort and 10 being the worse pain or discomfort) If you had to accept some level of pain or discomfort after completion of treatment, what would be an acceptable level? (On a scale of 0-10.With 0 being no pain or discomfort and 10 being the worse pain or discomfort) Dr. Keith S. Ungar Page 5
6 Is this condition interfering with any of the following? Sleep Work Daily Activities Housework Recreational Activities Walking Standing Shopping Musculoskeletal Do you have a spinal curvature or scoliosis? Y N Do you have arthritis? Y N If yes, where? What is your pain level? Best Worst Do you have joint pain? Y N What joints? What is your pain level? Best Worst Does your joint pain move around (i.e., from knees to shoulder)? Y N Do you have muscle pain? Y N Where? Do you get muscle cramps? Y N Where? Do you cramp when active? Y N What activity? Do you cramp when resting (i.e., in bed)? Y N Do you have any muscle/joint weakness? Y N Do you have difficulty walking? Y N If yes, why? Social History: Tobacco Do you currently use tobacco? Y N Type: cigars # per day How many years? Cigarettes # packs per day # per week How many years? chewing tobacco how many times in a day? How many years? Have you ever tried to quit the use of tobacco? Y N How many times? Did you ever use tobacco? Y N When? How long? How much? Were you (or are you) exposed to second-hand smoke? Y N Do you use recreational drugs (i.e, marijuana, cocaine, etc.)? Y N Beverages Liquids: Water: How many ounces of water (by itself) do you drink per day? What type of water? Filtered City / Well Spring Distilled Milk: Do you drink milk? Y N Type: Skim 1% 2% Whole Soy Almond How many glasses per day? Per week? Decaffeinated Beverages: Do you drink any caffeine-free beverages? Y N Type: Decaf Coffee Y N How many cups? Day Week Decaf Herbal Tea Y N How many cups? Day Week No-Caffeine Sodas Y N How many cups? Day Week Caffeinated Beverages: Do you drink any caffeinated beverages? Y N Type: Coffee: How many cups? Day Week Tea: How many cups? Day Week Soda/Diet Soda: How many cups? Day Week Name of soda: 2014 Dr. Keith S. Ungar Page 6
7 Alcohol: Do you consume any alcoholic beverages? Y N Type # per Day # Per Week # Per Month # Per Year Beer Wine Mixed Drinks Dietary Patterns: Infant Diet: Breast Fed? Y N Bottle Fed? Y N Childhood Diet: American? Y N Vegetarian? Y N Other? explain) Adult Diet: American? Y N Vegetarian Y N Other? (explain) Present Diet: American? Y N Vegetarian Y N Other? (explain) Do you follow a low-fat diet? Y N Not sure How many meals do you eat per day? What % of your meals are eaten at home? % What % are eaten out? % What % of the food you eat is cooked? % What % is raw? % Do you eat/consume any: Soy/tofu products? Y N If yes, how often? Do you use any soy nutritional supplements? Y N What foods or mixtures do you avoid and why do you avoid them? Do you have food cravings? Y N. If so, which foods or type of foods do you usually crave? What food do you sometimes crave (if any)? Exercise Habits Are you doing any type of exercise? Y N Consistently? Y N What type (ex. swimming, walking, aerobic, weights)? Type # times per week Length of time Please list all doctors you currently see: Primary doctor: For what condition(s) are you seeing him/her? Doctor #2: For what condition(s) are you seeing him/her? Doctor #3: For what condition(s) are you seeing him/her? 2014 Dr. Keith S. Ungar Page 7
8 Have you ever had any of the following tests? CAT Scan MRI Bone scan X-Rays Ultrasound Bone density EKG Stress EKG Other Test Other Test Other Test Type: Date(s) Area(s) Reason Type: Date(s) Area(s) Reason Type: Date(s) Area(s) Reason How willing are you to get your health back? On a scale of 1 to 10 with 10 being the MOST willing mark the number that best describes your motivation to: Significantly modify your diet? Least Most Take several nutritional vitamins each day? Least Most Keep a record of everything that you eat? Least Most Modify your lifestyle (diet,sleep,habits)? Least Most At the present time, how supportive do you think people in your household will be to your implementing the above changes? Least Most Where do you think you will be health-wise in 1 year if you DO NOT get help now? Where do you think you will be health-wise in 5 years if you DO NOT get help now? On a scale of 1-10 (10 being the most motivated), how motivated are you to getting your health back? Least Most Is health your top priority? Y N If no, why not? 2014 Dr. Keith S. Ungar Page 8
9 Additional Information: Is there anything you would like to add that I did not ask you? Health Goals What are your health goals if we accept you into care? Be specific and realistic! Examples: Decrease pain Decrease numbness, tingling, better balance etc Dr. Keith S. Ungar Page 9
10 Prescribed and Over the Counter Medications (not vitamins) Name Dosage # Times You Reason for Use How Many Years Take Per Day Example: Metformin 500 mg 2X Diabetes 10 Current Supplements (Vitamins) Name Dosage # Times You Reason for Use How Many Years Take Per Day Example: Vitamin D 1000 IU 2X Low Vit. D Levels Dr. Keith S. Ungar Page 10
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115 Stone Village Drive Fort Mill SC, 29708 P: 803-548-7300 F: 803-548-7301 www.yorkprimarycare.com New Patient Neuropathy Paperwork Name: First: Last: Today s Date of Birth: SS# Sex: MALE [ ] FEMALE [
Chiropractic Registration and History
Chiropractic Registration and History 1. Patient Information Name: Birthdate: SS/HIC/Patient ID #: Address: City: State: Zip: Phone: Cell: E-Mail: Sex: M F (Circle) Minor Single Married Divorced Separated
NEW SPINE PATIENT QUESTIONNAIRE
NEW SPINE PATIENT QUESTIONNAIRE Patient Name (please print) Date Age Birthdate Gender: Male Female Primary Care Doctor Phone# Referring Doctor Phone# We routinely send a copy of all clinic notes to your
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D. PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC Name: Age: Sex: Male Female Occupation: Job description: Date: PLEASE ANSWER THE FOLLOWING QUESTIONS: Major
The Johns Hopkins Diabetes Center JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT. Name: Marital Status: M S W SEP D
JOHNS HOPKINS DIABETES EDUCATION PROGRAM DIABETES SELF-MANAGEMENT ASSESSMENT Date: JHH # I. General Information Name: Marital Status: M S W SEP D Address: Phone: Home: Work: Email: Fax: Sex: M F Date of
Last Name: First Name: MI: 1. Have you recently had any major family changes: If yes, please explain:
Adult Medical Questionnaire Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully
Welcome to our office!
Vitality Chiropractic & Wellness Center 3348 Tyrone Blvd. St. Petersburg, FL 33710 WWW.DrWyckoff.com Phone (727) 381-7433 Fax (727) 381-7434 Welcome to our office! Please fill out our Health Record as
PATIENT HISTORY FORM
BodyCheck Prevention & Health Physical Therapy Centre PATIENT HISTORY FORM Please assist us by answering the following questions as completely and accurately as possible. Your answers will assist us by
Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No
PATIENT ENTRANCE FORM Date Circle: Male Female Name Birth Date (dd/mm/yy) Age Address Apt # City Province Postal Code Home # Cell # Work # E-MAIL Occupation Employer Name of Emergency Contact Contact #
Date: Chart # DC # Spouse / Parent / Legal Guardian Details: Name: Relation:
Leader Heights Spine, Joint & Nerve Associates Date: Chart # DC # Patient Information: Please print clearly and complete all sections. Please Circle : Mr. Mrs. Ms. Miss Dr. Rev. Marital Status : Single
INITIAL PATIENT FORM
Patient : INITIAL PATIENT FORM Reason for your visit: Visit Date: Left CIRCLE AREA(S) OF CONCERN: Right TOP/BOTTOM OUTSIDE INSIDE Type of pain: Sharp Burning Soreness Tightness Stabbing Numbness Aching
HOW WELL DO YOU REALLY EAT?
HOW WELL DO YOU REALLY EAT? To find out, think HONESTLY about each question and circle your answer. Then add up your score. How many servings of fruit do you usually eat per day? 1 serving = 1 med. Piece,
Please fill out completely. FACTORS OF COMPLAINT
DOB: Height: Weight: Please fill out completely. FACTORS OF COMPLAINT How and when did your problem begin? I don't know how it began It comes and goes. I've had it a long time ( years) Injury (date of
SPARROW FAMILY CHIROPRACTIC
Whom may we thank for referring you to this office? SPARROW FAMILY CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS PM#: Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail Address:
RED-ROSE CHIROPRACTIC CLINIC, P.S NE 85 TH STREET KIRKLAND, WA (425) fax (425)
PATIENT INFORMATION DATE: BP: P: Patient Name: (First) (Last) (M.I.) Address: City, State: Zip Code: Home #: ( ) Cell #: ( ) Work #: ( ) Date of Birth: Age: Sex: M / F Email: Automatic Appointment Reminder
Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
Physical Therapy & Rehabilitation 601 Texan Trail, Suite 250 Corpus Christi, Texas 78411 Telephone: (361)854-0811 EXT 221 Fax: (361)561-0609 www.southtexasboneandjoint.com Dear Patient, South Texas Bone
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
SLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:
q JHMCE q JHS q SMEH SLEEP QUESTIONNAIRE 1. DEMOGRAPHIC DATA Name: Home Telephone Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: 2. PHYSICIAN INFORMATION Name of Primary
Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ
Background Information Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ 08816. aberezrd@njpedsrd.com Adult Patient Nutrition Assessment/Diet History Form
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following