Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:

Transcription

1 An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work: Emergency contact: Name: Phone: Relationship: Referring provider (who sent you to us): Address: Phone: Primary Care Physician (family doctor): Address: Phone: Is your current medical problem accident related: YES or No Date of accident: Where were you injured? Home Work Auto Other Did you have a similar problem before the accident: Yes or No Do you have any pending medical litigation: Yes or No Date of lawsuit initiation: If so, please explain the nature of the lawsuit Name of attorney: Phone: Do you have ANY open worker s compensation claims: Yes No Date of Injury: Please explain the details of your claim: Please sign to verify the above information is correct:

2 PAST MEDICAL HISTORY: Type/When Diagnosed Psychiatric Yes No Any venereal disease Yes No Heart disease Yes No Heart attack Yes No High blood pressure Yes No Asthma Yes No Hepatitis Yes No Diabetes Yes No Polio Yes No Seizures Yes No Stroke Yes No HIV/AIDS Yes No Cancer Yes No Sleep apnea Yes No Other (list) Claustrophobia Yes No SURGICAL HISTORY: Please list all of your previous surgical procedures, including date of procedure Do you have any implants (shunt, pump, pacemaker, stimulator, etc.): Yes No If yes, what type: Date: ALLERGIES: No Known Allergies Medication, food, latex allergies: MEDICATIONS: Please list all medications you are currently taking, including dosages and frequency Patient, please sign to verify that all information is correct: Reviewed by provider:

3 SOCIAL HISTORY: Marital Status: Single Married Separated Divorced Widowed Education: High school diploma GED Highest grade completed College years completed: Degree: Work status: Are you currently working? Yes No Current occupation: Previous occupation: If you stopped working due to your current medical condition, date work stopped: Are you on disability? Yes No Applying for disability Yes No Smoking status: Never a smoker Current every day smoker ( packs per day, years smoking) Former smoker (when did you quit? ) Alcohol consumption: Never drink alcohol Stopped drinking alcohol (when? ) Currently drink alcohol (how much? how often? ) Do you have a drug addiction Yes No Previous? Yes No Are you currently receiving any type of pain medications from ANY provider? Yes No Please give details: Ordering provider: Are you established with ANY pain clinic? Yes No Details: FAMILY MEDICAL HISTORY: Current Age Medical Problems Age/Cause of Death Mother: Father: Brother/Sister: Brother/Sister: Brother/Sister: Son/Daughter: Son/Daughter: Son/Daughter: Patient, please sign to verify that all information is correct: Reviewed by provider:

4 REVIEW OF SYSTEMS: Please check answer if appropriate. CONSTITUTIONAL: migraines recent weight loss recent weight gain fevers travel abroad EYES: glaucoma cataracts vision problems OTOLARYNGEAL: ear problems nasal problems nosebleeds oral problems hoarsness cough CARDIOVASCULAR: shortness of breath palpitations irregular heartbeat circulation problems fluid in lungs heart murmur pacemaker chest pain angina RESPIRATORY: pneumonia bronchitis COPD tuberculosis recent cold emphysema sleep apnea GASTROINTESTINAL: ulcers gastritis GI bleeding liver disease cirrhosis jaundice colitis GU: renal failure urinary tract infection urinary frequency urinary urgency absence of one kidney Blood in urine discharge sexual complaints MALES ONLY: prostate problems loss of erection FEMALE ONLY: possible pregnancy date of last mammogram MUSCULOSKELETAL: osteoporosis bursitis neck pain back pain INTEGUMENTARY: skin problems psoriasis breast disease ENDOCRINE: thyroid problem taking steroids pituitary problem HEMATOLOGIC: lymph node problems enlarged glands bleeding problems easy bruising anemia ALLERGIC/IMMUNOLOGIC: seasonal allergies frequent infections HIV/AIDS Patient, please sing to verify that all information is correct: Reviewed by provider:

5 HISTORY OF PRESENT PROBLEM What is the reason for your visit today: Please describe your pain: Location of pain: Quality of pain (sharp, dull, aching, burning, etc.): Severity of pain, please rate your pain on a scale of 0-10: Is your pain constant: Yes No When did your problem begin: Was there a precipitating incident (fall, auto accident, etc.): Does anything make the pain better: Does anything make the pain worse: Do you have any numbness: Yes No If yes, where is the numbness: Any other symptoms: Conservative treatments: When/What type? Did it help? Physical Therapy Y N Y N Chiropractic Y N Y N Injections Y N Y N Steroids Y N Y N NSAIDS (ibuprofen, etc) Y N Y N Muscle relaxants Y N Y N TENS/muscle stimulator Y N Y N Other Y N Y N Patient, please sign to verify that all information is correct: Reviewed by provider:

6 CONSENT FOR COMMUNCATION AND/OR DISCLOSURE I request that the following alternatives or limitations relating to communications directed to me by my healthcare provider or employer. Marshall Health, Neuroscience. Do we have you permission to leave the following information on your home answering machine/voic ? Appointment Information: Yes No Billing Information: Yes No Medical Information: Yes No Do we have you permission to leave the following information on your mobile phone voic ? Appointment information Yes No Billing Information Yes No Medical Information Yes No Can we call you at work if necessary? Yes No I give my permission to share information with the following person(s): Patient signature: Date: Witness signature: Date: