MICHAEL N. BROWN, MD Interventional Regenerative Orthopedic Medicine Institute Physical Medicine & Rehabilitation Interventional Pain Management
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1 MICHAEL N. BROWN, MD Interventional Regenerative Orthopedic Medicine Institute Physical Medicine & Rehabilitation Interventional Pain Management th Avenue NE, Suite #22 Bellevue, WA 984 Office#: Fax#: WA DEA#: FB28688 WA LIC#: MD NPI#: TAX ID#: INTAKE HISTORY Name Date / / Address City St Zip Home Phone Cell Phone Work Phone Referred by Age Sex Weight Height Date of Birth / / Primary Care Physician Office # Health Insurance Carrier Health Insurance HISTORY OF PRESENT ILLNESS If you have more than one body area you want evaluated, please number the areas in order of severity and indicate Left or Right Neck pain Arm pain from neck Mid back pain Low back pain Leg pain from back Shoulder Elbow Wrist/forearm Hand Knee Ankle Foot Headaches Fibromyalgia Hips Please list other Do you participate with any form of state funded Medicaid Health Insurance program? INJURY: Are you claiming a work related or motor vehicle related injury at this time?: If yes, what type of injury are you claiming: Motor Vehicle Work Related Injury Other Injury such as slip and fall Date of Injury: DISABILITY: Are you currently on Social Security Disability? Are you receiving any other disability benefits? Are you planning on asking Dr. Brown for assistance in receiving disability benefits? Please provide a BRIEF chronological history of each problem checked above. Describe how the problem started, consultations and treatments you have received & anything else you think we need to know. Revised 4/1/218 1
2 PROBLEM #1: Location of pain: My pain remains: Localized Radiates Gradual Sudden Onset of pain: First onset of pain was: months ago years ago Pain is made worse by: Conditions is: Pain is relieved by: Radiates into my Sitting Standing Bending/Stooping Laying down Bending backward Exercise Other Getting worse Getting better Remains the same Sitting Rest Meds Heat Ice Walking Exercise Therapy Chiropractic Other Pain affects my work? Pain affects my relationships? Sometimes Sometimes Because of my pain I am unable to do things I like such as: Anything else the doctor needs to know about pain in this area: LEVEL OF PAIN IN PROBLEM AREA #1 On a scale of 1-1; suggests no pain and 1 suggests the worst pain possible, please describe the following: Pain at its least? Pain at its worst? Pain right now? How much does your pain interfere with sleep? PROBLEM #2: Location of pain: My pain remains: Gradual Sudden Onset of pain: First onset of pain was: months ago years ago Pain is made worse by: Localized Radiates Radiates into my Sitting Standing Bending/Stooping Laying down Bending backward Exercise Other Revised 4/1/218 2
3 Conditions is: Pain is relieved by: Pain affects my work? Pain affects my relationships? Because of my pain I am unable to do things I like such as: Anything else the doctor needs to know about pain in this area: LEVEL OF PAIN IN PROBLEM AREA #2 On a scale of 1-1; suggests no pain and 1 suggests the worst pain possible, please describe the following: Pain at its least? Pain at its worst? Pain right now? How much does your pain interfere with sleep? PROBLEM #3: Location of pain: My pain remains: Gradual Sudden Onset of pain: First onset of pain was: months ago years ago Pain is made worse by: Conditions is: Pain is relieved by: Pain affects my work? Pain affects my relationships? Getting worse Getting better Remains the same Sitting Rest Meds Heat Ice Walking Exercise Therapy Chiropractic Other Localized Sometimes Sometimes Radiates Radiates into my Sitting Standing Bending/Stooping Laying down Bending backward Exercise Other Getting worse Getting better Remains the same Sitting Rest Meds Heat Ice Walking Exercise Therapy Chiropractic Other Sometimes Sometimes Because of my pain I am unable to do things I like such as: Revised 4/1/218 3
4 Anything else the doctor needs to know about pain in this area: LEVEL OF PAIN IN PROBLEM AREA #3 On a scale of 1-1; suggests no pain and 1 suggests the worst pain possible, please describe the following: Pain at its least? Pain at its worst? Pain right now? How much does your pain interfere with sleep? Other pain or orthopedic problems (List body region effected): Please check all that describe your pain: Throbbing Shooting Stabbing Sharp Tingling Cramping Burning Aching Heavy Tender Splitting Tiring Exhausting Sickening Fearful Punishing Cruel What treatments have you tried? Medications Exercise Massage Chiropractic Acupuncture Brace Physical Therapy Hot Packs Ice Packs Nerve Block Injections Biofeedback TENS Unit Traction Psychologist Surgery Were any of these treatments helpful? Numbness Which were helpful? Sleep: Sometimes Do you have interference with your sleep? On the average how long does it take you to fall asleep? I sleep hours per night. If you wake, how long does it take to fall back asleep? Reason for sleeping difficulties? Do you snore? Do you wake gasping for air? Do you have sleep apnea? Do you use a BIPAP? Previous medications utilized? Revised 4/1/218 4
5 NSAIDS Relaxants Sleep medication Anti-depressants Narcotics Neuropathic pain medication Asprin Ibuprofin Advil Motrin Naprosyn Other Flexeril Valium Xanax Ativan Librium Other Ambien Restoril Benadryl Halcion Other Elavil (amitriptyline) Pamelor (nortriptyline) Prozac Effexor Desipramine Zoloft Restoril Paxil Serzone Remeron Other Vicodin Darvocet Tylenol #3 Codeine Percocet Percodan MS Contin Oxycontin Demerol Methadone Dilaudid Neurontin (gabapentin) Lyrica (pregabalin) Klonopin Tegretol Dilantin Baclofen Ultram (tramadol) Prozosin Mexiletine DIAGNOSTIC IMAGING In order to receive the most benefit from this comprehensive consultation, please provide all radiographic studies including the radiology report as well as a CD of the films or the original films themselves (ie; MRIs, CT Scans, X-rays, EMGs, etc). Dr. Brown reads and interprets your diagnostic imaging / tests himself; please do not rely of other doctors or medical facilities to forward your records. Please list the diagnostic imaging that you have previously had performed: Body part Date Imaging Center Results X-rays MRI CT Scan Bone Scan EMG Other PAST MEDICAL HISTORY Surgeries and/or hospitalizations? Any problems with surgery or anesthesia? If yes, explain Revised 4/1/218 5
6 Please provide a list of your past and present medical problems: Do you have a history of any of the following: HIV Hepatitis B Hepatitis C Previous accidents? Have you had any previous motor vehicle accidents? If yes, were you injured? Did you seek medical attention or treatment? General Skin Head Eyes se Ears Details of care/treatment Have you had any work related injuries? If yes, did you seek medical attention or treatment? Details of care/treatment Other accidents and injuries? REVIEW OF SYSTEMS Please check all that apply Recent weight loss Recent weight gain Fatigue Fever Change in apetite Night sweats Rashes Lumps Itching Dyrness Color change Hair or nail change Headaches Head injuries Dizziness Glasses Contacts Pain Double vision Redness Glaucoma Date of last exam / / Frequent colds Nasal stuffiness Hay fever sebleeds Sinus trouble Dust/animal allergies Hearing loss Mouth & Throat Date of last exam / / Neck Breasts Cardiovascular Peripheral Vascular Neurological Goiter Lumps/swollen glands Pain Date of last mammogram / / Bleeding gums Frequent sore throats Hoarseness Lumps Pain Nipple discharge Chest pain/angina Heart disease MI (heart attack) Congestive heart failure High blood pressure Peripheral vasular disease Abnormal heartbeat Pacemaker Angioplasty Rheumatic fever Damaged heart valve Hypercholesterolemia DVT (deep vein thrombosis) Palpitations Swelling of feet Shortness of breath Leg cramps while walking Varicose veins Thrombophlebitis Epilepsy/seizure Fainting spells with dizziness Stroke Headaches Fainting Blackouts Weakness Numbness Tremors Tingling in hands or feet Change in memory Revised 4/1/218 6
7 Gastrointestinal Ulcers Heaburn/reflux Diverticulitis/colitis Bowel incontinence Gallbladder disease Diarrhea Constipation Abdominal pain Hemorrhoids Jaundice (skin or whites of eyes turning yellow Other Genitourinary Frequent urinary tract infection Benign prostate hypertrophy Prostate cancer Stones Episodes with urination Urinary incontinence Sexual transmitted disease Frequent uination Painful urination Blood in urine Difficulty urinating or difficulty holding urination Waking up to go to the bathroom several times at night Respiratory Asthma Shortness of breath Emphysema Tuberculosis Pulmonary embolism Current smoker packs per day Past smoker: quit years ago, smoked packs per day Metabolic Diabetes Thyroid disease Adrenal gland problems Steroid use Liver/Kidney/Blood Kidney disease Shunt Graft / Fistula Dialysis Liver disease Gallbladder Anemia Hepatitis / type Easy bruising/bleeding Blood transfusions / years Anticoagulants/blood thinners Musculoskeletal Rheumatism Any rheumatologic disease Arthritis/osteoperosis Fractures Arthritis Joint stiffness Gout Muscle pains Muscle cramps Autoimmune Rheumatoid arthritis Polymalgia/rheumatica Lupus Scleroderma Other Psychological Depression Anxiety PTSD Panic/anxiety attacks Phobias Previous or curent psychiatric care Other Abuse Have you ever been hit, slapped, kicked or otherwise physically hurt by someone? Were you hurt in the past year? Were you hurt prior to this year? Has anyone ever forced you into having any type of sexual activity? Endocrine Heat intolerance Cold intolerance Excessive sweating Excessive hunger Excessive urination Cancer Type? Anything else in your past medical history? SOCIAL HISTORY: Single Married Divorced Widowed Employed Unemployed Social Security Disability Workers compenstation disability If you are not currently, when did you last work? What type of work do you do? Do you have children? Number of girls? Number of boys? How many live at home? Your education level High school College Revised 4/1/218 7
8 Graduate school SUBSTANCE ABUSE HISTORY: How many drinks containing alcohol do you have on an average week? Have you ever been concerned about your drinking? Has a friend, family member or healthcare worker ever been concerned about your drinking or suggested you cut down? I'm not sure t sure Do you smoke? If yes, How many cigarettes do you smoke per day? How old were you when you started smoking? Have you ever tried to quit? Are you interested in quitting? If a former smoker, how long ago did you quit? Please check any substances you have used (even if only once)? When was the last time you used? Have you EVER injected any type of substance? FAMILY HISTORY (Please check all that apply): Stroke Heart disease High blood pressure Thyroid disease Diabetes Kidney disease Asthma Arthritis Osteoperosis Migraine headaches Alcoholism Depression Anxiety Cancer / what type GYNECOLOGIC HISTORY: t applicable due to gender Have you ever had a hysterectomy? When? Were both ovaries removed? Menopause? Marijuana Cocaine Crystal meth Heroin Opiates (oxycontin, vidodin, etc Ecstacy/mushrooms/LSD Other If yes, please skip next 5 lines Why? Was 1 ovary removed? Left Right Date of last period / / Frequency of periods? (eg, every 28 days) Check all that apply Related headaches Weight gain Swelling Cramps Anxiety Depression Other Are you currently taking birth control? IF APPLICABLE: Revised 4/1/218 8
9 Age at menopause? Have you ever taken estrogen replacement? If yes, what was the name of the estrogen replacement? What age was estrogen replacement started? Have you ever taken progesterone? How long was it used? Please check all of the following symptoms of menopause you are experiencing? Hot flashes Fatigue Anxiety Depression Insomnia Irregular bleeding PLEASE BRING THESE COMPLETED FORMS WITH YOU TO YOUR INITIAL CONSULTATION WITH DR. BROWN. THANK YOU AND WE LOOK FORWARD TO MEETING WITH YOU. Revised 4/1/218 9
* CC* PATIENT QUESTIONNAIRE
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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:
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
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*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
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Salt Lake Orthopaedic Clinic Initial Visit Form
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McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
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LECOM Health Ophthalmology
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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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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Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
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ANY FAMILY HISTORY OF ANEURYSM OR DVT?
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Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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Patient History (Please Print)
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