PATIENT INTAKE FORM. Name Date of Birth Age. Address Sex. Home Phone Primary Care Physician. Address Phone # Referring Physician.
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1 PATIENT INTAKE FORM Date Name Date of Birth Age Address Sex Home Phone Primary Care Physician Address Phone # Referring Physician Address Phone # CHIEF COMPLAINT: Describe in your own words why you came to the Pain Clinic today: What are your expectations from your visit to the Pain Clinic today? HISTORY OF PRESENT ILLNESS: When did you first notice your pain/problem? What do you think caused your pain/problem? Where is your pain: (Please draw on figure on the last page) Is your pain worse on one side than the other, if so, which side? Describe your pain) for example, dull, sharp, burning, achy, etc.) Does your pain migrate or radiate to other parts of your body, if so, where?
2 Please use the following scale to rate your pain below: meaning no pain and 10 meaning severely painful.. My pain at BEST is My pain NOW is My pain at its WORST is List the things that make your pain better List the things that make your pain worse How is your sleeping? Have there been any changes in your mood? (for example, irritable, sad, not eating, etc.) If so please explain What have other physicians told you is causing your pain? Has your physician prescribed or have your tried any of the following forms of treatments for pain relief? If so, please note the date/s you tried or began treatment, the effectiveness (for example, good, bad, very, etc.) and the percentage of pain relief, if any. DATES EFFECTIVENESS %PAIN DECREASED Restricting activity Medication/s Ice/Heat Physical/occupational therapy Tens unit Chiropractic Biofeedback/counseling Nerve Blocks/Injections Surgery Is this pain the result of a work related accident: If yes, is legal action or an insurance settlement pending? If yes, describe the current status of such action
3 If no, do you plan to pursue legal action or insurance settlement in the future? Have you had any of the following pain related evaluations and if so please give the date/s and the facility in which you had the evaluations. DATES FACILITY(S) X-rays Cat scans MRI Myelogram Bone Scan Nerve and Muscle tests) EMG s Previous Medical History: Have you ever been diagnosed with any of the following medical conditions, and if so, when? DATE DIAGNOSED DATE DIAGNOSED Asthma/COPD High Blood Pressure Heart Disease Ulcers/GERD Kidney problems Hepatitis Bleeding tendencies Cancer Diabetes Other Previous Surgical History: Please list any surgeries, that you have had and the dates of those surgeries below: Surgery Date of Surgery Your Height Your Weight Drug Allergies Reaction Medications Dose
4 If you are currently taking a blood thinner please CIRCLE which one you are taking: LOVENOX PLAVIX COUMADIN REFLUDAN HEPARIN TICLID Social History: I work at I am retired from I have missed work in the month (Y/N) If yes, how many days? Tobacco use Y/N packs per day # years Quit Date Alcohol use Y/N amount/day History of abuse? Y/N Single Married Divorced Widowed I am: Pregnant Planning to become pregnant Y/N Does anyone live with you? If so, who? Education background: (circle all that applies) GED High School College Technical School Other Family History: Does any of your immediate family members have a history of a major disease: (For example: heart disease, lung disease, bone disease) if so, please list here: Mother Father Sister Brother Review of Systems: Do you have any of the following symptoms: Please list all symptoms that apply. CONSTITUTIONAL Fever/chills/sweats/weight change EYES,EARS, NOSE Headaches/eye, ear or nose problems CARDIOVASCULAR Chest pains/murmur/fluttering in chest RESPIRATORY
5 Short of breath/productive cough GASTROINTESTIONAL Diarrhea/constipation/incontinence NEUROLOGIC Weakness/loss of balance/falls SKIN Skin rash/hives/ulcers PSYCHIATRIC Depression/anxiety ENDOCRINE Diabetes/thyroid HEMATALOGIC Bleeding problems/anemia/swollen nodes ALLERGY/IMMUNOLOGIC Seasonal allergies/asthma/hay fever LATEX ALLERGY Have you ever been tested for a Latex Allergy? Y/N If so, what were the results? (Negative/Positive) Do you have eczema or problems with rashes: (Y/N) Do you have swelling, itching, hives or other symptoms after contact with: Balloons (Y/N) Dental Examinations or Procedure (Y/N) Vaginal or Rectal Exam (Y/N) Using a Diaphragm or Condom (Y/N) Wearing Rubber Gloves (Y/N) Have you experienced an unexplained anaphylactic episode? (For example: rapid heart, swelling of your throat and respiratory distress all at the same time) (Y/N) If yes, which one? FOOD ALLERGY Are you allergic to any of the following? IF so, indicate which ones and the reaction. Bananas/Avocados Kiwi Fruit/Chestnuts ** Nursing** If patients answers yes to BOTH a LATEX ALLERGY and ANY of the above questions were answered yes-note LATEX ALLERGY on the front of the chart. ASA CLASSIFICATION I II III IV V PHYSICIAN SIGNATURE DATE
6 PLAN OF TREATMENT Pain Clinic Patient Intake Form Please Shade on the drawing below where you feel pain.
7 Intake Form Completed Per Patient Responses Date: Nurse Signature
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD
Name: Height: Birthdate: Weight: Chief Complaint: What is the reason for your appointment? (please describe why you are here) Medications: Please list ALL medications with dosages you are currently taking,
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
Initial Pain Management Patient Questionnaire
Appt. Date: Appt. Time: Boston Out-Patient Surgical Suites North Tel Fax: 781-407-5892 Initial Pain Management Patient Questionnaire Dear New Pain Management Patient, Welcome to the New England Pain Management
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
GENERAL INFORMATION PROFESSIONAL REFERRAL INFORMATION
SO THAT WE MAY BETTER SERVE YOU, PLEASE COMPLETE THE FOLLOWING FORM AND EITHER BRING THE COMPLETED FORM WITH YOU TO YOUR FIRST APPOINTEMNT OR SCAN IT AND EMAIL IT TO OFFICE, PRIOR TO YOUR APPOINTMENT LORRAINE@ANALIPSONMD.COM
Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
Name: Age: Date: Accompanied by Relationship E-mail: @ MEDICAL BACKGROUND INFORMATION Please name the professionals that you have seen for this condition: Name Specialty Town Phone Who is your primary
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
New Patient Intake Form
New Patient Intake Form Please complete information below Name: DOB Age Male Female Referring Physician FAX Address Phone _ Primary Care Physician FAX Address Phone Is this a work related problem? If yes,
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
Pain Drawing. Name: Today s Date: How were you referred to the office: Visual Analog Scale
Pain Drawing Name: Today s Date: How were you referred to the office: Please be sure to fill this out as accurately as possible. This will become part of your permanent medical record and will be used
INITIAL PAIN EVALUTION QUESTIONNAIRE
INITIAL PAIN EVALUTION QUESTIONNAIRE We are interested in understanding more about your pain. Please help us by filling out this questionnaire. Please bring the completed questionnaire with you for your
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 These questions are general screening questions designed to identify areas where additional attention may be required. Please bring
BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM
PATIENT MEDICAL HISTORY FORM Name: Date: Social Security #: DOB: Height: Weight: Email: Primary Care Physician: Referred by: Pharmacy Name/Location/Phone Number: Dialysis Center and Phone Number (if applicable):
Initial Patient Intake Form
Initial Patient Intake Form Patient Registration Today s Date Patient Name (last) (first) (middle) Address (city) (state) (zip) Date of birth (mm/dd/yyyy) SSN # Current Gender Identity: Male Female Transgender
DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)
1275 Olentangy River Rd. Ste 120 Columbus, Ohio 43212 Telephone (614) 291-5555 Fax: (614) 291-7720 Dr. David B. Kaplansky Dr. Randall Contento PATIENT Dr. INFORMATION Garrett Kalmar FORM www.columbusohiopodiatrist.com
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
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
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
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight:
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight: I Referring Doctor Complete Name of Referring Doctor Last Complete Address
Pacific Coast Medical Group, PLLC dba Bellevue Pain Institute NE 8th St. Ste. 200 Bellevue, WA
PATIENT INFORMATION PHONE NUMBERS Date: Sex: M F Home: Work: Name: Address: City: State: Zip: Single Married Widowed Separated Divorced Cell: AT&T Verz T-Mob Nextel Virgin Sprint Email: Best time to reach
Salt Lake Orthopaedic Clinic Initial Visit Form
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SPINE PROGRAM NEW PATIENT FORM
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The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA C
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NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: Address: Relationship: Address:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: ( ) Marital Status: Married Single Divorced Widowed Cell Phone: (
Patient History Form
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Allina Health United Lung and Sleep Clinic
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PATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK 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:
MISSOURI SPINE INSTITUTE John D. Spears, D.O.
MISSOURI SPINE INSTITUTE John D. Spears, D.O. : / / Patient Name: Office Use Only Right/Left Handed BP: / Pulse: Height: Weight: BMI: Primary Care Physician: Cardiologist: of Birth: / / Age: Sex: M F Please
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Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
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Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
Name Date Date of Birth. Age Sex: M F Height: ft. in. Weight lbs. Primary Physician Referring Physician (If Different) When did the pain begin?
(Please fill out this form and bring it with you to your appointment.) Name of Birth Age Sex: M F Height: ft. in. Weight lbs Primary Physician Referring Physician (If Different) CURRENT PROBLEM Please
Name: Sex: Male Female. Date of Birth: Occupation: Is this an accident or work related injury?
Name: Sex: Male Female Date of Birth: Occupation: Is this a 2 nd opinion? Yes No Is this an accident or work related injury? Please list: Family MD: Referring MD: Address: Address: Phone: Phone: Fax: Fax:
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Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
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Hospital he hospital is located near the interchange of highway 217 and (US 26).
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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.
1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
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Cell Phone #: Home Phone #: ** Address (prefer your forever address):
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Medical History Form
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Please continue on reverse side
"Committed to making a difference in the quality of life in those we serve and those with whom we work" Patient Information Today s Date: Social Security Number: - - First Name: M.I. Last Name: Suffix:
Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone
Date Patient Last Name First Name Middle Name Gender (circle): Male Female Other: Marital Status (circle): Single Married Divorced Widowed Separated Home Address City State Zip Date of Birth Age Social
Please fill out this form as completely as possible. This information will determine how we treat your pain problem.
Name Date of birth Age Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your
Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
Last Name First Name MI: Address City State Zip. Referring Provider. Employer Address. Emergency Contact Relationship Phone. ID # Group # ID # Group #
Patient Demographic o New Patient o Return Patient o Update Account #: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave
New Patient Intake Form
501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
Patient: First Name Middle Initial Last Name. Date of Birth SSN. Address . City State Zip Code. Home Phone ( ) Cell Phone ( )
PATIENT DEMOGRAPHICS PATIENT INFORMATION Patient: First Name Middle Initial Last Name Date of Birth SSN Gender: Male Female Address Email City State Zip Code Home Phone ( ) Cell Phone ( ) Occupation Employer
Orthopedic Care Specialists Spine Center
Date of Intake: Orthopedic Care Specialists Spine Center Patient Name: Date of Birth: Primary Care Physician Name: Primary Care Physician Address: Primary Care Physician Phone Number: What is the reason
Other doctors to receive copies of records : Chief complaint / history of present illness (Describe why you have been referred here):
Patient Name: Date: Age: Date of Birth: Preferred Name: Preferred Language: Address: City: State: Zip: Phone: Cell Phone: Preferred Phone: Emergency Contact: Relationship: Email: If you would like to opt
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:
Patient Label (Office Use)
Name: Patient Label (Office Use) VVMC Diversified Services Health History Survey And Contact Information Please provide the following information so we may contact you as needed. We may contact you to
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