OhioHealth Orthopedic & Sports Medicine Physicians
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- Abraham Henderson
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1 Page 1 of 6 OhioHealth Orthopedic & Sports Medicine Physicians 335 Glessner Avenue, Mansfield, Ohio PATIENT INTAKE ASSESSMENT OFFICE USE ONLY Fax to: OR Control For Joint Replacement and Inpatient Spine Procedures OR Control to fax to: Occupational Therapy: Physical Therapy: Social Service: PST Date Time Surgery Date Approach MRSA Swab obtained in office YES NO IF YES Name: Today s Date: Address: City: Zip: Occupation: Age: Height: Weight: (BMI: to be completed by office nurse) How did you get referred to this office? Primary Care Physician: Name: REASON FOR TODAY S VISIT: HISTORY OF PRESENT ILLNESS THAT BRINGS YOU HERE TODAY: Do you have pain? Where is the location of your pain? When did it start? How long have you had this pain? Rate your pain on a scale of 0 to 10 (10 being the most painful): Is the pain: О Constant О Occasional О Sharp О Dull О Aching О Stabbing О Throbbing What, if anything, makes your pain better? What, if anything, makes your pain worse? What other symptoms are you experiencing? Have you seen another physician for this problem? If yes, who? What treatments have you tried? О Physical Therapy О Exercise О Acupuncture О Chiropractic О Massage О Injections О Medications What type of exercise or activities or hobbies do you enjoy?
2 Page 2 of 6 Do you have difficulty putting on or taking off your shoes and socks? Please check: Do you use assistive devices to walk? Please check: О Walker О Cane О Crutches How far can you walk? Please Check: О 0-2 City Blocks О 3-6 City Blocks О 7-12 City Blocks О Unlimited MEDICAL HISTORY: О Irregular Heartbeat О High Blood Pressure О High Cholesterol О Heart Disease О Blood Clots О Cancer О Diabetes О Asthma О Emphysema О Strokes О Seizures О Liver Disease О Rheumatoid Arthritis О Osteoarthritis О Thyroid Disease О Anemia О Heart Attack О HIV О Chemical О Alcoholism О Depression О Hepatitis B or C О Chemical О Kidney Disease О Other Are you followed by a cardiologist? Your cardiologist s name: Phone: ( ) Are you followed by any other specialist? Name Specialty: Phone: ( ) GASTROINTESTINAL History Do you have a history of a stomach ulcer (peptic ulcer disease)? If yes, when: Do you take any medications for your stomach? Please include over the counter medications: i.e., Pepsid, Tums, Zantac, etc.) PAST SURGICAL HISTORY: FILL in circle completely and note date Surgery Date Surgery Date О No prior surgery О Prostate О Bowel Removal О Thyroid О Head/Brain О Lower Back О Kidney/Stone О Hysterectomy О Cataract Right О Hemorrhoid О Cataract Left О Lung О Heart/Bypass О Fracture О Appendix О Gall Bladder О Vascular О Stomach О Skin О Other
3 Page 3 of 6 MEDICATIONS: Please list ALL medications you are currently taking or provide list to nurse. Please include antibiotics, blood thinners, insulin, heart medications, aspirin, and any other over-the-counter medications including vitamins, minerals and herbal supplements. Medication Dosage Frequency Reason for Medication ALLERGIES: Please check: О No known drug allergies, Allergic to: О Penicillin О Sulfa О Latex Other Type of Reaction to Allergy: Please list all other allergies: SLEEP APNEA EVALUATION: (Fill in circle completely if yes) Have you had recent weight gain of more than 15 lbs in the past year? Have you ever been seen by a sleep specialist? If yes, name of doctor: Have you ever had a sleep study done? If yes, what lab? Have you ever been prescribed APAP, or BiPAP? Have you ever been prescribed oxygen? Do you snore? Do you snore loudly? Have you ever been told that you stop breathing when you sleep? Are you tired, sleepy or fatigues during the day? Do you wake up mornings with a headache?
4 Page 4 of 6 SOCIAL HISTORY: (only check if yes) Do you live alone? Who lives with you? Do you have Children? How many Occupation? What type of work do you do? Do you have stairs in the home? How many stairs do you have to climb to enter the home? Tobacco use? Number of packs per day: Duration: Quit date: Alcohol use? Frequency: Recreational drug use? Frequency: What services do you currently receive in the home? Meals on Wheels? Home Health Care? Name: Senior programs? Name(s): Do you have transportation to go to outpatient therapy if needed? What equipment do you have at home? О Walker О Crutches О Commode Chair О Shower Chair/Bench Other: FAMILY HISTORY: (please note next to condition if Father, Mother or Sibling) Condition Father/Mother/Sibling Condition Father/Mother/Sibling О Heart Disease О Diabetes О Blood Clots О Cancer О Hypertension О Stroke О Seizures О Respiratory (chronic cough) О Other REVIEW OF SYSTEMS: Please fill in circle completely if you have any of the following current symptoms or current known medical problems in the following areas: CONSTITUTIONAL: О Weight Loss О Weight Gain О Insomnia О Chronic Fatigue О Fever EYES: О Recent vision change О Cataracts О Glaucoma О Any history of metal fragments in the eye? EARS, NOSE, THROAT: О Loss of Hearing О Seasonal Allergies О Hearing aids О Dental issues
5 Page 5 of 6 HEART: О Chest pain О Angina О Hypertension О Heart Murmur О Irregular pulse О Palpitations О Shortness of Breath О High Cholesterol О High Triglycerides О Bypass Surgery О Pacemaker О Stent RESPIRATORY: О Asthma О Wheezing О Shortness of Breath О Pneumonia or Bronchitis О Emphysema/COPD О Sleep Apnea Date and location of last chest x-ray: GASTROINTESTINAL: О Heartburn О Indigestion О Acid Reflux О Ulcer О GI, Stomach Bleed О Blood in Stools О Colon Cancer Constipation О Diarrhea SKELETAL: О Arthritis О Muscle Weakness О Joint Pain О Back Pain О Fibromyalgia О Reflex Sympathetic Dystrophy О Joint Replacement О Bone Infection О Swelling Multiple Joints SKIN: О Chronic Rash О Ulcers О Eczema О Psoriasis О Skin Cancer or Melanoma NEUROLOGICAL: О Numbness О Weakness or loss of sensation in arms or legs О Leg pain/sciatica О Loss of Bowel or Bladder Control О Seizures О Headaches PSYCHIATRIC: О Depression О Anxiety О Claustrophobia О Other Psychiatric Problems ENDOCRINE: О Diabetes О Hypothyroid О Hyperthyroid О Hot Flashes О Hormone Replacement О Taken Prednisone
6 Page 6 of 6 HEMATOLOGY: О Anemia О Easy Bruising О Easy Bleeding О Blood Transfusion, When GYNECOLOGICAL: О Breast Cancer О Ovarian Cancer О Cervical Cancer О Fibroid Tumors GENITOURINARY: : О Bladder Infections О Blood in Urine О Difficulty with Urination О Kidney Stones О Prostate Problems О Urgency О Hesitancy О Nocturia (urinating during the night) PRINT NAME: SIGNATURE: DATE: PHYSICIAN SIGNATURE DATE:
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
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Patient Information. Insurance Information
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Morris Medical Center, P.A.
Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~
Patient Data Sheet. Emergency Contact Name: Relationship: Contact phone number: Name: Specialty: Office address: Office phone: Fax:
Today s Date: / / Your Information Patient Data Sheet Last ame: First: MI: Sex: M F Date of Birth: / / Age: SS: Address: Home phone: Cell phone: Can we leave message on Home? Y or Cell? Y Are you currently
Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
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Salt Lake Orthopaedic Clinic Initial Visit Form
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New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
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CENTRAL COAST ORTHOPEDIC MEDICAL GROUP Medical History Questionnaire GENERAL INFORMATION
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I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
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* CC* PATIENT QUESTIONNAIRE
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Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
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Medical History Form
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
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Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
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Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
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