Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
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- Jack Stafford
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1 Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency ALLERGIES: Do you have any drug allergies? Yes No If yes, please describe the allergy and the reaction: Do you have any other allergies we should know about? Yes No If yes, please describe the allergy and the reaction: FAMILY HISTORY: Family Member Alive/Deceased Age Medical Problem(s) Mother A D Father A D Are there diseases which are common in your family? (If yes, please list.) Has any family member had a history of surgery for their back or neck, or had problems with their back or neck? Page 1 of 5
2 Patient Name: SOCIAL HISTORY: Occupation: A: Physically, do you consider your job: Heavy Moderate Light B: If retired, what was your prior occupation? Is someone available to care for you in your home if the need arises? Yes No Do you live in a: House Apartment Other: #of stories: Do you exercise regularly? Yes No Describe: Do you have a history of drug abuse or drug addition? Yes No Alcohol use: Tobacco use: I use alcohol: Never Occasional Moderate Heavy I have a history of heavy alcohol use: Yes No Do you smoke? Yes No I currently smoke packs per day and have smoked for years Are you at risk for AIDS/HIV (e.g. sexual history, drug use, previous transfusion)? Yes No PAST MEDICAL HISTORY: Please circle yes or no Y N Use of Blood Thinners Y N Anxiety Disorder Y N Aortic Aneurism Y N Arthritis Y N Asthma Y N Bipolar Disorder Y N Cancer Y N Congestive Heart Failure Y N COPD (Chronic Obstructive Pulmonary Disease) Y N Head Injury, without skull fracture Y N HIV Y N High Cholesterol Y N High Blood Pressure Y N Heart Attack Y N Infectious Diseases (e.g. MRSA, TB) Y N Osteoarthritis Y N Coronary Artery Disease Y N Osteoporosis Y N (CVA ) Stroke Y N Rheumatoid Arthritis Y N Degenerative Joint Disease Y N Depression Y N Seizue Disorder Y N Diabetes Y N Sleep Apnea Y N Fibromyalgia Y N Thyroid Disease Y N Glaucoma Y N Tuberculosis Y N Head Injury, with skull fracture Y N Vertebral Artery Stenosis Complications from any surgery? No Yes Please Explain Do you take antibiotics before procedures or dental work? No Yes Why? Page 2 of 5
3 Patient Name: PAST SURGICAL HISTORY: Please list all previous surgical procedures and the date your surgery was performed. Carpal Tunnel Spinal Cord Injury Craniotomy Spinal Cord Stimulator Discectomy Spinal Fusion Lumbar Endarterectomy Spinal Fusion Thoracic Intracathecal Pump Ulnar Nerve Release Kyphoplasty Vertebroplasty Laminectomy Cervical Laminectomy Lumbar Other Appendectomy Heart Surgery C Section Angioplasty Gall Bladder Removal Bypass Dental Stent D&C Valve Replacement Eye Surgery Other Fracture Repair Hernia Repair Rotator Cuff Repair Hysterectomy Thyroidectomy Sinus Surgery Subtotal Pancreatic Surgery Total Prostatectomy Tonsillectomy Large Bowel Resection Tubal Ligation Small Bowel Resection Vasectomy Stomach Resection Other REASON FOR VISIT: Describe your current problem and how it began. Please list all symptoms leading to today s visit: Page 3 of 5
4 REASON FOR VISIT cont d: Date symptoms began: Is your current problem a result of: Car Accident Work Accident Other/Unknown Date of injury/accident: Are you currently off work because of your problems? Yes No Is a lawyer involved in your case? Yes No If yes, name of lawyer: PAIN HISTORY: (if not applicable, skip to next section) What makes your symptoms better? What makes your symptoms worse? What specific activities are you having difficulty with that you hope to change as a result of treatment? In order to get better, you will be expected to participate in your treatment. This may include doing exercises or avoiding certain activities. How committed are you to participating in your treatment? Very Committed Somewhat Committed Not Very Committed Is there anything that will limit your ability to participate in therapies? Yes No Please Explain: What tests have you had for your problem? X rays Ct Scan MRI Blood Tests Other: What treatments have you had for your problem? Medication(s) Physical Therapy Chiropractic Injections Surgery Other: Please describe their effect: Would you consider surgery if it were recommended? Yes No REVIEW OF SYSTEMS: Please circle yes or no General: Y N Weight gain greater than 10 lbs Y N Weight loss greater than 10 lbs Y N Obesity Skin: Y N Bruising Neck: Y N Neck Mass Y N Swollen Glands Respiratory: Y N Chronic Cough Y N Difficulty Breathing Page 4 of 5
5 Patient Name: HEENT: Musculoskeletal: Y N Blurred Vision Y N Back Pain Y N Head Injury Y N Muscle Cramps Y N Double Vision Y N Arm Weakness Y N Visual Disturbances Y N Leg Pain Y N Visual Loss Y N Neck Stiffness Y N Hearing Loss Y N Ringing in the Ears Neurological: Y N Seasonal Allergies Y N Decreased Memory Y N Hoarseness Y N Difficulty Speaking Breast: Y N Nipple Discharge Y Y N N Dizziness Fainting Cardiovascular: Y N Headaches Y N Chest Pain Y N Incoordination Y N Irregular Heart Beat Y N Loss of Consciousness Y N Elevated Blood Pressure Y N Seizures Y N Rapid Heart Beat Y N Stroke Y N Shortness of Breath Y N Weakness in Extremeties Y N Swelling of the Feet Y N Leg Pain with Walking Gastrointestinal: Y N Change in Bowel Habits Psychiatric: Y N Indigestion Y N Anxiety Y N Jaundice Y N Depression Y N Nausea Y N Inability to Concentrate Y N Vomiting Endocrine: Genitourinary: Y N Thyroid Problem Y N Change in bladder habits Hematology: Y N Frequency Y N Abnormal Bleeding Y N Hesitancy Y N Anemia Y N Incontinence Y N Blood Clots Other: The above information is accurate to the best of my knowledge: Please Print Name Signature Date I HAVE REVIEWED THE ABOVE INFORMATION (Office Use Only) Page 5 of 5 Physician Name Signature Date Reviewed Page 5 of 5
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?
New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:
New Patient Packet Patient Name: DOB: Age: Sex: Male / Female Height: Weight: PHYSICIAN CARE Primary Care Physician: Address: City: State: Zip: Phone: Fax: Referring Physician (if different from PCP):
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
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:
New Patient Intake Form
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
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)
Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving
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
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:
Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
PAIN TREATMENT CENTER
PAIN TREATMENT CENTER Name Date Age Occupation Referring Doctor Have you ever been a patient of a Pain Clinic or Center? Yes No If yes where: When did you first notice symptoms of your pain problem? 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
MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History
MEDICAL INFORMATION TODAY S DATE: SOCIAL SECURITY NUMBER: PATIENT NAME: BIRTHDAY: HEIGHT: WEIGHT: AGE: WHO REFERRED YOU? RACE: PRIMARY CARE PHYSICIAN: SEX: DOCTOR S ADDRESS: SECTION 1: Pharmacy Information
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
Health History Intake Form;
Health History Intake Form; Today s Date: Patient Name: Date of Birth: Age: Previous Primary Care Physician (if any): Phone: Address: Other Physicians involved in your care: Reason for visit today: Allergies
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
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
GUPTA SPORTS & SPINE CENTER
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New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
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
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
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
*** ADDRESS: (If address is not provided, you MUST write Patient denied.)
PATIENT INFORMATION NORTHWEST BROWARD ORTHOPAEDICS DATE: ***E-MAIL ADDRESS: (If e-mail address is not provided, you MUST write Patient denied.) Pharmacy Name: Pharmacy Phone Number: Pharmacy Location PATIENT
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
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
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week
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OhioHealth Orthopedic & Sports Medicine Physicians
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Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
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VASCULAR SURGERY PATIENT HEALTH HISTORY
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Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
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
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
SURGERY SPECIALTY PATIENT HEALTH HISTORY
SURGERY SPECIALTY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
WELCOME TO FALLS CHIROPRACTIC AND INJURY!
WELCOME TO FALLS CHIROPRACTIC AND INJURY! PATIENT INFORMATION (Most of the information below is required for insurance purposes) DATE: / / FIRST NAME: M.I.: LAST NAME: DATE OF BIRTH: / / CALLED NAME /
PATIENT REGISTRATION
PATIENT REGISTRATION "Please PRINT clearly and fill out form COMPLETELY and hand all insurance cards for copying ** First Name: Last Name: Middle Initial: Address: Apt #: City: State: Zip: Date of Birth:
New Patient Medical History Form
New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring