Thomas Kremen, MD ORTHOPAEDIC SURGERY AND SPORTS MEDICINE
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- Calvin Bertram Thomas
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1 Thomas Kremen, MD ORTHOPAEDIC SURGERY AND SPORTS MEDICINE New Knee Patient Intake Questionnaire PLEASE PRINT Please provide your referring physician s name, address (if known, if not list the city) and phone number (if known): What problem brings you in today (circle ONE item from each line below)? Left Knee Right Knee Both Left and Right (which side is worse? ) Pain Swelling Unstable joint Decreased motion Other: Do you have any catching, locking or bones moving out of place? Yes No How long has your knee hurt? (how many days, weeks, months, or years?) Was this knee problem the result of a specific injury or no specific injury? (Generally injuries that occurred many years ago and did not causing constant disability can be considered no specific injury) Yes, my injury was: No specific injury How severe would you rate your knee pain on a scale of 1 to 10? (refer to scale below)
2 How would you rate your knee today as a percentage of normal (0% to 100% scale with 100% being normal)? % Ci r c l e any pr ev i ous t r eat m ent s: P h y s i c a l T h e r a p y In j e ct i o n Su r g e r y Have you taken NSAIDs? Yes No Did they help with your pain? Yes No Examples of NSAIDs: ibuprofen (advil, Motrin), Naproxen (Naprosyn/Aleve), Diclofenac (Voltaren), Meloxicam (Mobic) Where does your knee hurt? (circle or mark area below) Right Knee (front and side views) Left Knee (front and side views)
3 Please check all that apply: CARDIOVASCULAR Chest Pain Irregular heart beat Poor circulation Dizziness Rapid heart rate Swelling of ankles CONSTITUTIONAL Chills/fever Fainting Headache Loss of sleep Unplanned weight loss Loss of appetite Night sweats ENDOCRINE Rapid weight loss/gain Intolerance to warm room Multiple broken bones Cessation of menstrual periods Excessive hunger/thirst Loss of libido Thyroid disease Diabetes Pregnant? Low Vitamin D HEMATOLOGIC Swollen lymph nodes Easy skin bruising Prolonged bleeding from cuts, tooth extractions Blood clots in the past? Sickle cell disease IMMUNOLOGIC Autoimmune disease Rheumatoid arthritis Psoriasis Ankylosing spondylitis Are you HIV positive? Joint infections in the past Bone infections in the past Chronic infections anywhere in the body INTEGUMENTARY Skin rashes or eruptions Bruises Redness Draining wounds MUSCULOSKETAL Multiple joint pains Lower back pain Neck pain Broken bones Joint replacements NEUROLOGIC Fainting Headaches Numbness of arms or legs Electric pain in arms or legs Seizures Tingling of hands, feet, arms or legs Bowel incontinence Bladder incontinence (spilling urine abnormally) PSYCHIATRIC Anxiety Depression Panic attacks Restlessness Bipolar disease Attempted suicide in the past RESPIRATORY Cough Shortness of breath Wheezing Coughing up blood Pneumonia DENTAL: Dental infections Gum disease
4 Do you have any medical problems? (Example: Diabetes, Cancer, Heart attack, Stroke, high blood pressure, gastroesophageal reflux, autoimmune disease, Rheumatoid arthritis, Thyroid problems, Marfans, Ehlers Danlos) Have you ever had surgery in the past? (Example: Gall bladder removed, appendix removed, tonsils removed, broken bone surgical repair, pacemaker implanted, cancer surgery, spine surgery) Current Medications: Name of Medication Dose How often do you take it? Ex: twice a day, once a week Allergies to medications and type of reaction:
5 Family History of Medical Problems: If yes, explain Father: qyes qno Mother: qyes qno Grandparents: qyes qno Siblings: qyes qno Social History: Do you smoke? (includes cigars/pipes/vaping) Do you drink alcohol? Yes No If yes, how many packs per day? Yes No If yes, how many drinks per week do you drink? Do you use any other drugs? Yes No If yes, what substances do you use? How often do you use these substances? Occupation: With whom do you live currently (circle one)? Alone Parent(s) Spouse (significant other) Homeless Other: PE: PLEASE LEAVE THIS SPACE BLANK (for office use only) PLAN:
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
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
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?
Gregory H. Tchejeyan, M.D., Inc. Please fill out this form in its entirety. Please complete every line item, as it is necessitated by regulations from the government (Health Care Finance Administration
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
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
Past Medical History. Chief Complaint: Appointment Date: Page 1
Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
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WILLIAM S. CRAWFORD, MD NEW PATIENT INTAKE FORM Patient Name: DOB: INSTRUCTIONS: Please complete the following questionnaire before you see the doctor. Answer each question in as much detail as possible.
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Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency 1 2 3 4 5 6 7 8 9 10 11 12 13
CENTRAL COAST ORTHOPEDIC MEDICAL GROUP Medical History Questionnaire GENERAL INFORMATION
GENERAL INFORMATION Last Name: First Name: What name do you prefer to be called? Age: DOB: / / Height: Weight: Left or Right Handed : Right Left Marital Status: M S D W Name of spouse or significant other:
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Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
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
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
Patient Name: Date of Birth:
Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?
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WILLIAM K MONTGOMERY, MD
WILLIAM K MONTGOMERY, MD Knee and Hip Joint Replacement Specialist New Patient Questionnaire NAME: DOB: / / AGE: Your Primary Care Physician: Phone Number: Referring Physician: Phone Number: Are you a
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
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
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MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
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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
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Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
MEDICAL QUESTIONNAIRE (male)
MEDICAL QUESTIONNAIRE (male) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501/502 Fax: 01 2780248 The appointment comprises of a discussion about this questionnaire and a subsequent
Premier Internal Medicine of Alpharetta, PC
Patient Information Date / / First Name Middle Initial Last Name Date of Birth / / Social Security # Gender Male Female Marital Status Single Married Separated Divorced Widowed Address Apt # City State
Spine New Patient Questionnaire Rev
Spine New Patient Questionnaire Rev 10.13.10 Name: Male Female Temp: Height: Weight: Date of Visit: Date of Birth: Age Today: *Please note this is a multi-part questionnaire. When you are done, please