PAIN SOLUTIONS NEW PATIENT QUESTIONNAIRE
|
|
|
- Baldwin Beasley
- 5 years ago
- Views:
Transcription
1 PAIN SOLUTIONS NEW PATIENT QUESTIONNAIRE Patient Name: DATE Primary Doctor: Referring Doctor: Please show the location of your pain by drawing on the figures below:
2 Pain History (PLEASE FILL IN THE BUBBLES) 1. WHERE IS YOUR PAIN LOCATED? O Low Back O Neck O Mid-back O Face O Head O Right arm O Left arm O Right leg O Left leg 2. WHERE DOES THE PAIN RADIATE? O Right leg O Left leg O Both legs O Right arm O Left arm O Both arms O Other 3. THE PAIN FIRST STARTED: O 1 O 2 O 3 O 4 O 5 O 6 O 7 O 8 O 9 O 10 O days ago O weeks ago O months ago O years ago O other Was there an accident or injury that caused the pain? O NO O YES 4. HOW WOULD YOU DESCRIBE YOUR PAIN? (mark all that apply) O aching O throbbing O sharp O dull O nagging O shooting O burning O numb O tingling O stabbing O Other 5. RATE YOUR PAIN AT IT S WORST IN THE LAST 24 HOURS? Worst Pain Pain Imaginable 6. RATE YOUR PAIN AT IT S BEST IN THE LAST 24 HOURS? Worst Pain Pain Imaginable 7. HOW SEVERE IS YOUR PAIN ON AVERAGE? Worst Pain Pain Imaginable 8. HOW MUCH DOES THE PAIN INTERFERE WITH YOUR ACTIVITIES? 0% % Completely Interference Interferes 9. HOW MUCH DOES THE PAIN INTERFERE WITH YOUR SLEEP? 0% % Completely Interference Interferes 10. THE PAIN IS: O constant O intermittent O worse in am O worse in afternoon O worse in evening O worse at night 11. WHAT MAKES THE PAIN WORSE? O standing O walking O sitting O lifting O bending over O other 12. WHAT MAKES THE PAIN BETTER? O standing O walking O bending
3 O lifting O sitting O lying down O ice O heat O medications O other 13. IN ADDITION TO THE PAIN, DO YOU HAVE? O Numbness O Weakness O In the right arm O In the left arm O In both arms O In the right leg O In the left leg O In both legs O New bladder incontinence O New bowel incontinence O ne of these 14. IS YOUR PAIN: O getting better O getting worse O staying about the same 15. WHAT TESTS HAVE YOU HAD FOR YOUR PAIN? (Please list date of last exam) O X-rays O MRI Scan O CT Scan O EMG O Other 16. WHAT MEDICATIONS HAVE YOU TRIED FOR YOUR PAIN? (Check ALL that apply) Anti-Inflammatory: O Ibuprofen (Advil, Motrin) O Naproxen O Celebrex O Aspirin O Relafen O Meloxicam (Mobic) O Indomethicin Narcotic: O Morphine O Avinza O MSIR O MS Contin O Kadian O Dilaudid O Oxycodone O Oxycontin O Percocet O Percodan O Darvocet O Darvon O Hydrocodone O Vicodin O Lortab O Lorcet O rco O Fentanyl O Duragesic O Actiq O Fentora O Codeine O Tramadol O Ultram O Stadol Antidepressants O Duloxetine (Cymbalta) O Fluoxetine (Prozac) O Escitalopram (Lexapro) O Trazodone (Deseryl) O Venflaxine (Effexor) O Sertraline (Zoloft) O Amitriptyline (Elavil) O rtriptyline (Pamelor) O Desipramine (rpramine) O Buproprion (Wellbutrin) O Citalopram (Celexa) O Paroxetine (Paxil) O Nefazodone (Serzone) Anti-Seizure O Gabapentin (Neurontin) O Pregabalin (Lyrica) O Zonisamide (Zonegram) O Carbamazepine (Tegretol) O Lamotrigine (Lamictal) O Oxycarbazepine (Trileptal) O Tiagabine (Gabatril) O Topiramate (Topamax) Muscle Relaxants/ O Baclofen (Lioresal) O Tizanidine (Zanaflex) O Metaxolone (Skelaxin) Anti-Anxiety O Cyclobenzaprine (Flexeril) O Methocarbamol (Robaxin) O Carisoprodol (Soma) O Diazepam (Valium) O Clonazepam (Klonopin) O Alprazolam (Xanax) Sleeping Aids O Zolpidem (Ambien) O Eszopiclone (Lunesta) O Zalepion (Sonata) O Trazodone (Deseryl) O Amitriptyline (Elavil) O Temazepam (Restoril) O Triazolam (Halcion) O Tylenol PM Other Pain Meds O Lidoderm Patch O Flector Patch O Topical Gel O Mirapex
4 17. WHAT TREATMENTS HAVE YOU HAD FOR YOUR PAIN? O Physical therapy O Water Therapy O Traction O Exercise O Yoga O Psychology O Acupuncture O Chiropractic O Massage O TENS O Biofeedback O Hypnosis O Rolfing O Trigger Point Injections O Facet Injections O Epidural Injections O Nerve Blocks O Spinal Pump O Spinal Cord Stimulator O Other Past Medical History (Please Fill in yes or no to all questions) CARDIOVASCULAR Cardiac Arrythmia Heart Attack Coronary Artery Disease Atrial fibrillation Mitral Valve Prolapse Congestive Heart Failure High Blood Pressure High Cholesterol DVT (blood clot) RESPIRATORY Asthma COPD - Emphysema Sleep apnea NEUROLOGY TMJ Seizures Trigeminal Neuralgia Headache - Migraines Headache - Tension Headache - Cluster Post-herpetic Neuralgia Multiple Sclerosis Myasthenia Gravis Stroke PSYCH Anxiety/depression Bipolar Disorder Schizophrenia Dementia GASTOINTESTINAL Irritable bowel syndrome Peptic ulcer disease Indigestion/acid reflux Hiatus hernia Hepatitis B Hepatitis C Ulcerative Colitis OTHER Kidney stones Kidney Failure Kidney Disease Hypothyroidism Lupus Cancer What kind? Osteoporosis Fibromyalgia Arthritis - Rheumatoid Osteoarthritis RSD Anemia Diabetes(insulin) Diabetes(no insulin) Social History
5 Do you drink Alcohol? O O Yes O Occasionally O daily O weekly Do you smoke? O O Yes O <1ppd O 1ppd O 2ppd O 3ppd Do you exercise? O O Yes Do you work? O O Yes O Full-time O Part-time O Unemployed due to pain O Homemaker O Retired Occupation Do you use Illegal Drugs? O O Yes O Used in the past Drug(s) Used OTHER SYMPTOMS (Please indicate other symptoms you may have) CONSTITUTIONAL Fever Fatigue Insomnia Weight loss Weight gain Loss of Appetite GI Abnormal bruising Abnormal bleeding NEUROLOGY Seizures Headache Memory loss Numbness Where? Blood in stool Diarrhea Vomiting Constipation Nausea Difficulty swallowing Abdominal pain Heartburn URINARY Urinary retention Incontinence RESPIRATORY Wheezing CARDIOVASCULAR Dizziness Chest pain Palpitations Leg swelling Shortness of breath ENT Cough MUSCULOSKELETAL Joint pain Joint stiffness Back pain Muscle weakness PSYCH Depression Sleep disturbances Suicidal ideation Anxiety HEMATOLOGY
6 CURRENT MEDICATIONS (Include dosage and # tablets per day) Have you had any surgeries? Are you taking any of the following blood thinners? Coumadin Plavix Do you have any allergies to medications? Latex Iodine Other Medications? What are your goals for your pain treatment? Are there any specific treatments that you would like for your pain? Medications: Physical Therapy: Exercise: Psychologist referral: Surgery referral Injections: Other pain therapies: (Please circle) acupuncture chiropractic massage TENS DRX9000 Pool exercise biofeedback Other Do you have a driver with you today? yes no THIS IS THE END OF THE QUESTIONNAIRE. THANK YOU!
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE PATIENT NAME: PRIMARY DOCTOR: DATE: REFERRING DOCTOR: Please show the location of your pain by drawing on the figures below: Pain History 1. WHERE IS YOUR PAIN LOCATED? 0 Low
PAIN INFORMATION SHEET
PAIN INFORMATION SHEET PLEASE MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE SENSATIONS DESCRIBED BELOW. PLEASE USE THE APPROPRIATE SYMBOL & INCLUDE ALL AREAS. **** ==== OOOO XXXX //// ACHE **** NUMBNESS
New Patient Intake Form. Please List All Current Medications. Please shade in the areas where you have pain
New Patient Intake Form Name: Date: Referring Physician Primary Care Physician Please List All Current Medications Do you take Coumadin/Warfarin/Plavix/Lovonox or Aspirin? Yes No Last dose? Please shade
Initial Pain Questionnaire
Initial Pain Questionnaire Date: Name: Address: Last First Middle Initial Street Address City State Zip Home Phone Cell : Work: Referring Physician: Other Physicians: Age: PAIN HISTORY: What is the main
Legacy Pain Management Center New Patient Questionnaire
Legacy Pain Management Center New Patient Questionnaire Please complete this form prior to your visit to allow us to make the best use of our time together. Primary Care Provider: Referring Physician:
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:
DOB Age Sex Weight Height Right Handed Left handed
Lee Ann Brown, D.O. Date: Patient Name DOB Age Sex Weight Height Right Handed Left handed Marital Status S M D W Is your problem related to: Car /Bike accident Yes/No Date Slip or Fall accident Yes/No
NEW PATIENT INFORMATION SHEET
Akintomi A. Olugbodi M.D. 301 S. Seventh Ave. Suite 315 West Reading, PA 19611 (484) 869-2817 NEW PATIENT INFORMATION SHEET PLEASE COMPLETE THESE FORMS PRIOR TO YOUR APPOINTMENT AND BRING THEM WITH YOU
Chayapathy Jollu, MD Board Certified in Physical Medicine and Rehabilitation Patient Initial Pain Questionnaire
Patient Initial Pain Questionnaire Date: Last Name: First Name: Middle Name: Age: Gender: M F Right handed Left handed Referring Physician: Primary Care Physician: Address: Address: Phone: Phone: Fax:
NEW PATIENTS' INFORMATION SHEET
NEW PATIENTS' INFORMATION SHEET Please print clearly. Please complete all information so that your claim can be processed quickly and efficiently. Thank you! PATIENT INFORMATION (First) (MI) (Last) Name
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
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
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
Using the symbols below, please draw in the location of your symptoms on the diagrams. X = Pain 0 = Numbness / = Aching * = Pins & Needles
Date: DOB: Age: Gender: Right handed: Left handed: Who referred you? Is your problem related to : Job injury Date: Car accident Date: Date: Briefly describe your main problem/complaint. Also, describe
Other physician #1. #(p) List any allergies to medications. Please list below all other current medical conditions or previous surgeries
Dept. of Obstetrics and Gynecology Division of Gynecological Pain and Minimally Invasive Surgery Frank Tu, MD, MPH Sangeeta Senapati, MD, MS Howard Topel, MD Name: New Patient Intake Questionnaire Names
ACCOUNT NO. MED. REC. NO. NAME BIRTHDATE
OC4501 Oregon Health & Science University *OC4501* Page 1 of 15 Thank you for completing this form prior to your appointment. Please use blue or black ink. If you have difficulty completing this questionnaire,
COMPREHENSIVE REHABILITATION PAIN QUESTIONNAIRE. Date of Visit. Statement of Problem: Date of Injury/onset of condition: Date of birth: Age
5226 Indian River Road, Suite 102, Virginia Beach, VA 23464 COMPREHENSIVE REHABILITATION PAIN QUESTIONNAIRE Please complete and bring to appointment Name Address Home Phone: Date of birth: Age Date of
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Phone (302) 355-0900 Fax (302) 355-0901 Web delmarvapain.com PATIENT INFORMATION & REGISTRATION Name: Date of Visit: Referring Physician: Date of Birth: Age: Primary Care Physician:
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
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C ADULT SPINE HISTORY For Office Use Only: HR: BP: / Name of Patient: Date: Date of Birth: Age: Height: ft in Weight: lbs Form
PATIENT DEMOGRAPHIC INFORMATION
PATIENT HISTORY FORM Date of Visit: Steven E. Levine, MD PATIENT DEMOGRAPHIC INFORMATION Name: Last First Middle Initial Home Address City / State Zip ( ) ( ) Home Phone Cell Phone Email Address Date of
Morris Medical Center, P.A.
Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~
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,
Tips for Pain Management
Tips for Pain Management Going for the 3 Increases: Increase in Health, Increase in Happiness & Increase in Energy Strategies for Success in Health Management By: James J. Messina, Ph.D. What are the medical
black marker and color the circles completely. There are 3 ways you can get these forms to us: 1. Fax to us (and bring originals to your appointment):
Please fill out the enclosed 8 page questionnaire. Use a no. 2 pencil or a black marker and color the circles completely. There are 3 ways you can get these forms to us: 1. Fax to us (and bring originals
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
1 UT Health Austin Comprehensive Pain Management New Patient Questionnaire Thank you for scheduling a visit with the Comprehensive Pain Management Care Team. The responses you provide to these questions
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
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
Beno Kuharich, D.O. Interventional Spine/Pain
Patient Information Today s date: Your name: Date of Birth: Age: Referring Physician: Primary Care Physician: Pain History Chief Complaint (Reason for your visit today)? Does this pain radiate? If so where?
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,
Center for Pain Management New Patient Intake Form
Center for Pain Management New Patient Intake Form Your completed intake paperwork helps our physicians and other providers get to know you and your medical history better. We rely on its accuracy and
Patient Data Sheet. Emergency Contact Name: Relationship: Contact phone number: Name: Specialty: Office address: Office phone: Fax:
Today s Date: / / Your Information Patient Data Sheet Last ame: First: MI: Sex: M F Date of Birth: / / Age: SS: Address: Home phone: Cell phone: Can we leave message on Home? Y or Cell? Y Are you currently
NEW PATIENT INFORMATION FORM
1031 WEST WILLIAMS STREET, SUITE 102, APEX, NC 27502 PHONE (919) 439-7867 FAX (919) 573-9594 NEW PATIENT INFORMATION FORM All patients (new and returning) are subject to the following no-show/broken appointment
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
Southern Interventional Pain Center New Patient Evaluation Form
Southern Interventional Pain Center New Patient Evaluation Form Page 1 of 5 Name: D.O.B. Today s Date: Chief Complaint and History of Present Illness Please list your DAILY SEVERE AREAS OF PAIN only: LOW
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:
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.
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
FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE
FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE Please circle answers to the questions that pertain to your problem. You may select more than one answer per question. This information will
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
CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:
JOSE G. VELIZ MD, INC. Diplomate of the American Board of Interventional Pain Management Diplomate of the American Board of Anesthesiology Diplomate of the American Board of Pain Medicine Fellow of Interventional
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
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -SPINE Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
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
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
INITIAL COMPREHENSIVE PAIN QUESTIONNAIRE
INITIAL COMPREHENSIVE PAIN QUESTIONNAIRE Name: DOB: Address: Phone number: Referring Physician name: PAIN HISTORY: Was the pain a result of a particular incident (injury, accident, illness): No Yes (please
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
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
Eastern Shore MediCann Clinic, LLC
Eastern Shore MediCann Clinic, LLC New Patient Medical History and Intake Form Medical Marijuana Certification Name Date of Birth Social Security Number Gender: Male Female Address: Street: City: State
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
New Patient Evaluation
ECPC Pain Specialists 2430 Emerald Place, Suite 103 Greenville, NC 27834 252-561-8218 ECPC Pain Specialists complies with applicable federal civil rights laws and does not discriminate on the basis of
«ProviderFirstLastName» Interventional Spine/Pain
Patient Information Today s date: Your name: Date of Birth: Age: Referring Physician: Primary Care Physician: Pain History Chief Complaint (Reason for your visit today)? Does this pain radiate? If so where?
PSYCHIATRY INTAKE FORM
Please complete all information on this form. PSYCHIATRY INTAKE FORM Name Date Date of Birth Primary Care Physician Current Therapist/Counselor What are the problem(s) for which you are seeking help? 1.
CENTRAL COAST ORTHOPEDIC MEDICAL GROUP Medical History Questionnaire GENERAL INFORMATION
GENERAL INFORMATION Last Name: First Name: What name do you prefer to be called? Age: DOB: / / Height: Weight: Left or Right Handed : Right Left Marital Status: M S D W Name of spouse or significant other:
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
New Patient Questionnaire HIP Adult Reconstruction & Joint Replacement
New Patient Questionnaire HIP Adult Reconstruction & Joint Replacement Name: DOB: Date: Height: Weight: Age: Chief Complaint Laterality Left Right Both Please describe your symptoms: (Mark all that apply)
Medical History Questionnaire
Date Medical History Questionnaire Name DOB Reason for visit When did symptoms first appear Is the condition getting worse? Please rate your pain 0 1 2 3 4 5 6 7 8 9 10 No Pain Extreme Pain Please circle
NEW SPINE PATIENT. Date Seen: Blood Pressure: Pulse: Weight: Height: O 2. How long (days, weeks, or years) has this complaint/problem been going on?
ROOM #: NEW SPINE PATIENT Date Seen: Blood Pressure: Pulse: Weight: Height: O 2 Sats: For office use only above this line. Patient Name: Referring Physician: Date of Birth: Age: Insurance Carrier: Present
Patient Information. Last Name: First Name: Middle Initial: Address: Address 2: City: State: Zip: Primary Phone: Work Phone:
Patient Information Last Name: First Name: Middle Initial: Address: Address 2: City: State: Zip: Primary Phone: Work Phone: Email: SSN: DOB: Gender: Male Female Marital Status: Single Married Divorced
NEW SPINE PATIENT QUESTIONNAIRE
NEW SPINE PATIENT QUESTIONNAIRE Patient Name (please print) Date Age Birthdate Gender: Male Female Primary Care Doctor Phone# Referring Doctor Phone# We routinely send a copy of all clinic notes to your
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?
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
PAIN QUESTIONNAIRE. Patient Name: Patient Date of Birth: Appointment Date:
Patient Name: Patient Date of Birth: Appointment Date: Please mark and/or notate the areas of your body which are affected by pain. RIGHT RIGHT LEFT LEFT RIGHT LEFT RIGHT RIGHT LEFT LEFT RIGHT LEFT For
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
Today s Date: Date of Birth: Age: Height: Weight: Who Referred: If not referred, how did you choose this office? Why are you seeing the doctor today?
Name: Today s Date: Date of Birth: Age: Height: Weight: PCP: Who Referred: If not referred, how did you choose this office? Why are you seeing the doctor today? Please list major complaint(s) and describe
ACCOUNT NO. MED. REC. NO. NAME BIRTHDATE
OC4501 Oregon Health & Science University *OC4501* Page 1 of 15 Thank you for completing this form prior to your appointment. Please use blue or black ink. If you have difficulty completing this questionnaire,
Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency 1 2 3 4 5 6 7 8 9 10 11 12 13
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
New Patient Questionnaire KNEE Alejandro Gonzalez Della Valle, MD
New Patient Questionnaire KNEE Alejandro Gonzalez Della Valle, MD Name: DOB: Date: Height: Weight: Age: Chief Complaint Laterality Left Right Both Please describe your symptoms: (Mark all that apply) Throbbing
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?
NEW PATIENT INFORMATION
OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
HPM. Huntsville Pain Management Specialists in Interventional Pain Management James D. Thacker, M.D. NEW PATIENT MEDICAL INFORMATION
NEW PATIENT MEDICAL INFORMATION Patient Name: OTHER CARE PROVIDERS Name Phone Number Referring Provider: Primary Care Physician: Previous Pain Doctors: Spine or Back Surgeon: Anyone else you would like
Spine & Pain Center. On the diagram, shade the area where you feel pain. Put an X on the area that hurts the most.
NEW PATIENT : : Physician: : Patient Label On the diagram, shade the area where you feel pain. Put an X on the area that hurts the most. What is your pain right now? Circle the number that best reflects
New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification
Name Social Security Number Address: Street: _ New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification Date of Birth Gender: Male Female City: State Zip Code E-mail: Home Phone:
New Patient Pain History Form
New Patient Pain History Form Name: Date of Birth: / / Today s Date: / / Date the Pain Began: / / Reason for visit: Describe what caused the pain (accident, injury, etc.): Pain 1. Pain/Symptom Description
Lynx Healthcare. How did you hear about Lynx
Lynx Healthcare How did you hear about Lynx Lynx Healthcare. Lynx Healthcare Lynx Healthcare TRI-CITIES ADDRESSES 3730 Plaza Way, Suite C6100 Kennewick, WA 99336 7401 W Hood Place, Suite 200 Kennewick,
INITIAL PAIN QUESTIONNAIRE
INITIAL PAIN QUESTIONNAIRE 501 Cetronia Road, Suite 125 Allentown, PA 18104 830 Ostrum Street Bethlehem, PA 18015 3 Parkinsons Road East Stroudsburg, PA 18301 1700 St. Luke s Boulevard, Suite 200 Easton,
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. If you already completed this form in the last 3 months, please fill
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. Thank you for your cooperation. Patient
Personal Information:
Personal Information: Last Name: First Name: Middle Initial: Previous Name(s): Address: City: State: Zip: Date of Birth: / / Social Security: - - Gender: Male Female Home Phone: ( ) - Cell Phone: ( ) -
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
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
DEPARTMENT OF NEUROSURGERY Spine Center New Patient Intake Form
DEPARTMENT OF NEUROSURGERY Spine Center New Patient Intake Form Today's date: Your name: Date of birth: Email address: CHIEF COMPLAINT What is the main reason that you are seeking medical attention? Please
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
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?
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
ASSIGNMENT OF BENEFITS
ASSIGNMENT OF BENEFITS PATIENT NAME: First Middle Last PHONE NUMBER: Home: Work: HOME ADDRESS: City ZIP AGE: DOB: SSN: Status EMAIL ADDRESS: PATIENT EMPLOYER: How long? Occupation SPOUSE S EMPLOYER: Spouse
Patient Name: Cell Phone Home Phone Work Phone. Address City State Zip Address
Patient Name: Date Cell Phone Home Phone Work Phone Address City State Zip Email Address Sex M F Marital Status M S D W Date of Birth Age Social Security Number Occupation Employer Referred by Have you
MICHAEL N. BROWN, MD Interventional Regenerative Orthopedic Medicine Institute Physical Medicine & Rehabilitation Interventional Pain Management
MICHAEL N. BROWN, MD Interventional Regenerative Orthopedic Medicine Institute Physical Medicine & Rehabilitation Interventional Pain Management 1515 116 th Avenue NE, Suite #22 Bellevue, WA 984 Office#:
Numbness: o o o o o. Grade your overall pain. Pain Rating Scale Mosby. Worst Possible Pain. No Pain HURTS LITTLE MORE HURTS EVEN MORE
Patient Name: Original Referring Physician: Current PCP: PAIN DIAGRAM Is your condition the result of a: Work injury? YES NO Auto accident? YES NO Date of Injury: / / Please mark the areas of discomfort
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
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
Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week
3 Washington Circle W, #207/208 Patient ame: Age: Chief Complaint: Please describe what you are being seen for today: What is your hand dominance (which hand do you write with)? Left Right Ambidextrous
Lynx Healthcare
Lynx Healthcare Lynx Healthcare. Lynx Healthcare Lynx Healthcare TRI-CITIES ADDRESSES SPOKANE ADDRESS ALLERGY & PAIN MGT 12709 E Mirabeau Pkway Bldg A Ste 200 Spokane Valley, WA 99216 NEW MEXICO ADDRESS
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / / Email Address: Do not have email Do not wish to provide Date of Birth: / / Gender: Male
New Patient Questionnaire
Patient Information New Patient Questionnaire Name DOB Gender Date: Address: City: State: Zip: Home Phone Cell Phone Are you employed? Occupation Work Phone Email Address How did you hear about our clinic
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