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1 GENERAL NEW PATIENT HISTRY What is the MAIN injury/problem you are seeing the doctor for today? IF UNLISTED CHSE THE CLSEST. right shoulder pain left shoulder pain head right arm pain left arm pain neck right elbow pain left elbow pain chest right forearm pain left forearm pain midback right wrist/hand pain left wrist/hand pain low back right hip pain left hip pain problems walking right thigh pain left leg pain weakness right knee pain left knee pain numbness and/or tingling right calf pain left calf pain another problem right foot/ankle pain left foot/ankle pain Date injury/problem began (APPRXIMATE IF UNSURE): Yes No Is your problem a result of an injury/problem? Check any of the following that What caused your injury/problem? happened at the time of your injury/problem: Fall Felt pain Lifting Heard popping Throwing Had swelling Reaching Dislocation Pulling Fracture Fighting Deformity Twisting Bruising Sports Collision/Contact Another cause ther: What conservative treatment have you had on or since your injury/problem began? Injection Anti-inflammatory medication Heat Aspiration Pain Medication Ice Physical Therapy Chiropractic Care Massage Exercise Bracing Rest 1 of 7
2 PAIN Are you having pain today? Is your pain today: Yes ccasional No Continuous/Constant n a scale of 0-10 (with 10 being the worst pain imaginable, how would you score your pain today?) 0 6 Morning 1 7 Afternoon 2 8 Evening 3 9 Nighttime 4 10 All the time 5 What time of day is your pain worst? Check the words that best describe the character of the pain you are having today: aching pain nagging pain shooting pain burning pain numbness tenderness exhausting pain throbbing pain unbearable pain gnawing pain sharp pain miserable pain stabbing pain What makes your symptoms better? rest sitting sports/exercise medication standing brace/cane/crutch ice walking sleeping heat squatting physical therapy lying down stretching injection nothing in particular ther factors that makes the pain better: What makes your symptoms worse? lying down twisting/pivoting stairs sitting activity in general reaching standing stooping/bending overhead activity walking lifting pushing sports/exercise squatting pulling nothing in particular ther factors that makes the pain worse: 2 of 7
3 REVIEW F SYSTEMS General recent weight gain recent weight loss appetite change difficulty sleeping fevers problems walking (balance problems, falling) night sweats Eyes difficulty seeing loss of vision double vision blurred vision ENT & Mouth none difficulty hearing nose bleeds swallowing difficulty sinus problems Pulmonary (lungs) shortness of breath dry cough productive cough (sputum) bronchitis asthma sleep apnea Gastrointestinal heartburn / indigestion difficulty swallowing stomach pains ulcers nausea / vomiting diarrhea hemorrhoids rectal bleeding black bowel movements change in bowel habits constipation frequent laxative use jaundice or hepatitis liver trouble gallbladder problems Endocrine / Metabolic diabetes goiter thyroid problem sterility cholesterol / lipid problem Genitourinary burning on urination frequency of urination difficulty starting urine wetting pants or bed bloody urine sexual difficulties Skin ecchymotic purulent drainage (pus) swollen erythematous (red) rash itching easy bruising / bleeding slow healing Cardiovascular high blood pressure chest pain heart attack palpitations (irregular heart beat) heart failure edema (leg swelling) Musculoskeletal joint pain joint deformity joint swelling / warmth joint stiffness muscle pain weakness neck pain back pain Neurologic headaches dizziness blackouts numbness and tingling paralysis convulsions / seizures coordination trouble Hematopoietic / Lymphatic anemia lymph node enlargement frequent infections excessive bleeding blood clots Psychiatric anxiety depression difficulty sleeping appetite changes confusion memory loss been seen by a psychiatrist leg cramps (when walking) fainting coldness in hands and/or feet loss of hair on arms or legs abnormal color (blue, white, red) in hands or feet other 3 of 7
4 MEDICAL CNDITIN HISTRY N MEDICAL PRBLEMS Depression Alcoholism Gout Anemia HIV Anxiety Hypertension (High Blood Pressure) Arthritis inflammatory Hypercholesterolemia (Elevated Cholestero (rheumatoid) Arthritis oseto, degenerative Hypothyroidism Bowel disease Kidney Disease Cancer Liver Disease (Cirrhosis, Hepatitis) Cardiac Arrhythmia (abnormal Lung Disease (CPD, emphysema) heart rate) Congestive Heart Failure steomyelitis Coronary Artery Disease (Angina) Parkinson s Cerebrovascular Disease (Stroke) Ulcer Disease Diabetes ther: PREVIUS RTHPAEDIC SURGERY/PRCEDURES Arthroscopy Right shoulder Left shoulder Right elbow Left elbow Right wrist/hand Left wrist/hand Right hip Left hip Right knee Left knee Right foot/ankle Left foot/ankle Joint Replacement Surgery Right shoulder Left shoulder Right elbow Left elbow Right wrist/hand Left wrist/hand Right hip Left hip Right knee Left knee Right foot/ankle Left foot/ankle ther rthopedic Surgeries: Fracture Repair Right shoulder Left shoulder Right arm Left arm Right elbow Left elbow Right forearm Left forearm Right wrist/hand Left wrist/hand Right pelvis Left pelvis Right hip Left hip Right femur (thigh) Left femur (thigh) Right knee Left knee Right tibia/fibula Left tibia/fibula Right foot/ankle Left foot/ankle Spine Surgery Cervical Thoracic Lumbar Previous Non-rthopedic Surgeries Abdominal surgery Gallbladder surgery tonsillectomy Brain surgery Gynecologic surgery Urology surgeries Cancer surgery Hernia repair Vascular surgery Cardiothoracic surgery Plastic surgery ther Eye surgery Sinus surgery ther Surgeries: 4 of 7
5 FAMILY MEDICAL HISTRY Please check all diseases for which you have a family history: Arthritis, Rheumatoid (inflammatory) Diabetes Arthritis, Degenerative Heart Disease Cancer Breast High Blood Pressure Cancer Prostate High Cholesterol Cancer ther Lung Disease Dementia Stroke ther: SCIAL HISTRY Current Employment: Full time Part time Retired Student Unemployed Disabled Level of Education: Grade School High School/Equivalent Some College College Degree Graduate Degree Exercise: Do not exercise regularly nce per week 3-5 times per week daily Drugs: Do not use drugs cocaine marijuana other Alcohol: Never use alcohol Used to drink but stopped Rarely drink alcohol (<1/month) Drink occasionally (1-4/month) Drink socially (1-2/week) Drink frequently (3-5/week) Drink daily (1/day) Tobacco: does not use tobacco products has never smoked tobacco uses chewing tobacco used to smoke tobacco but stopped currently smokes less than ½ pack per day currently smokes ½-1 pack per day currently smokes 1-2 packs per day currently smokes more than 2 packs per day ther Drugs: 5 of 7
6 MEDICATINS AND ALLERGIES Are you currently taking any medications? Yes No Patient Current Medications: Medication Name Dose For what purpose? Do you have any allergies? Yes No Please list all allergies (including iodine and contract dyes): Allergy Severity 1 Mild Moderate Severe 2 Mild Moderate Severe 3 Mild Moderate Severe 4 Mild Moderate Severe 5 Mild Moderate Severe 6 Mild Moderate Severe 7 Mild Moderate Severe 6 of 7
7 Pharmacy Name PREFRERRED PHARMACY INFRMATIN Pharmacy Street Address City, State, Zip If address unknown please provide crossroads Pharmacy Phone Number Thank you for taking the time to complete this form on your initial visit. The information provided will assist us in ensuring you receive Florida rthopaedic Institute s high quality care during your visit with us today. We look forward to keeping you active! Everything I have answered is true and correct to the best of my knowledge. Patient Signature: Date: 7 of 7
Patient Name: Date:_. MR#: --,.- ROY SANDERS MD - PATIENT HISTORY-ADDITIONAL PAGE PATIENT INFORMATION 4/24/2014 1
Patient Name: ate:_. MR#: --,.- ROY SANERS M - PATIENT HISTORY-AITIONAL PAGE PATIENT INFORMATION Primary Physician Information Family/Primary Physician: Family/Primary Physician address and phone #: Who
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Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
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 Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C
Interventional Pain Medicine P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Gainesville Braselton Medical Park 1, Suite 300 Medical Plaza B, Suite 402 1315 Jesse Jewell Parkway 1404 River
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Phone ( ) Age Birth Date Sex S.S.N. Employer Address Did you report this to YOUR Car Insurance? Yes No (Circle One) Your Car Insurance Co. is Claim # Claims Adjuster
The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION
The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION Name: Email: Daytime Phone Number: Date of Birth: / / Age: How did you hear
Dr. Hall New Patient Paperwork Please fill out these forms completely
Dr. Hall New Patient Paperwork Please fill out these forms completely Date of Appointment Complete the enclosed packet and bring it to the appointment along with all X Rays, MRI disc and reports. Please
PATIENT INTRODUCTION
PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via
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
PATIENT PERSONAL / CONFIDENTAL DATA
PATIENT PERSONAL / CONFIDENTAL DATA Address: City: State: Zip Code : H. Phone: W. Phone: Cell Phone: Date of Birth: Age: Sex: M F Marital Status: M S D W Email Address: Social Security # Name of Spouse:
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
Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider