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1 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 Date Job injury Yes/No Date (Describe events surrounding injury on back of this page.) Briefly state the reason for your visit and the body part(s) affected? (I.e. arm/leg /neck/back/knee/shoulder/ hip/etc. If you have NECK PAIN, what percentage of your pain is %Neck and %Arm (Total 100%) If you have BACK PAIN, what percentage of your pain is %Back and %Leg (Total 100%) X= pain O = Numbness / = Aching *= Pins & Needles 1
2 How long has your current problem existed? Have you had this particular problem before? Yes / No If yes, when did it occur and how long did it last? Have you experienced any focal weakness? (i.e. drop foot) Yes / No Have you experienced any numbness or tingling in arms or legs? Yes / No Have you experienced any loss of control of bowel or bladder? Yes /No Rate your pain ( ) LEAST WORST What makes the pain worse? (Please check all that apply) Walking Standing (>15min) Sitting Moving from sitting to standing Riding in car Lying down on stomach Lying down on back Coughing Bowel movement Worse Comments What makes your pain better or at best, eases your pain? Better Comments Sitting Lying down Standing Heat Ice Packs Medications (specify) Massage Adjustments Do you need assistance to help you walk? Yes/No If yes, circle the type of support? (Walker/ Cane/ Other Do you wear a back or neck BRACE? Yes/No (What type) 2
3 DRUG ALLERGIES Drug Type of Reaction FAMILY HISTORY Age Alive Decreased Medical History or Cause of death Father Mother Sibling 1 Sibling 2 Sibling 3 Sibling 4 PAST MEDICAL HISTORY X Comments X Comments Serious infection Osteoporosis Cancer (type) Pacemaker Depression Anxiety Psoriasis Heart Disease Rheumatoid arthritis Bleeding disorder Degenerative arthritis High Blood Pressure Lupus Diabetes Bowel disorder Kidney Disease Stroke Lung Disease Thyroid Multiple myeloma Ulcers/ (indicate if bleeding) Plavix/Coumadin High cholesterol Herniated disc seizures Immunocompromised Others Mark the diagnostic tests you have had in regards to your main complaint. Test Dates Test Date Test Date Plain X-ray Nuclear Bone Myelogram Scan MRI EMG/NCV Arthrogram CT scan Dexa scan Discogram Other: 3
4 Mark the TREATMENTS you have had and indicate how many times it was administered. Treatment X Helpful Yes/no Epidural steroid injection Facet injection Sacroiliac injection Hip injection Radiofrequency ablation Nucleoplasty Vertebroplasty RIT ( prolotherapy) Trigger points Nerve blocks # of injections Dates of each List all SURGERY(S) Type Date Outcome List the PREVIOUS PHYSICIANS (MD, DO, Chiropractor) you have seen for your main complaint Physician Specialty Treatment / testing 4
5 Social History- Work Status/ Education Occupation Highest Education Level Full Duty Light Duty off Duty per Physician Unemployed Retired If you are NOT working full duty: How long have you been off work? Have you had a work capacity assessment? Yes No Are you disabled through Social Security? Yes No Substance abuse: Have you ever been treated for drug or alcohol addiction? Yes/ No Explain (include substance abused and date and treatment date if any received ALCOHOL USE Do you currently consume alcoholic beverages? Yes No If yes, indicate the quantity per day: Beer Wine Distilled spirits TOBACCO USE Do you currently use tobacco products? Yes No Started Year Stopped If yes, indicate the quantity per day: Cigarettes Cigars Chewing tobacco List ALL CURRENT MEDICATIONS Name Dose (milligrams, grams) How often (how many times a day) How Long 5
6 Mark which of the following medications you have ever taken and if it helped. Medication x Helpful Medication Yes/No x Helpful Medication Yes/No Aspirin Darvocet Roxicodone Tylenol Avinza Actiq Ibuprofen Kadian MS contin Advil Hydrocodone Morphine Motrin Vicodin Methadone Celebrex Lortab Norco Mobic Percocet Opana Relafen Oxycodone Cymbalta Naproxsyn Oxycontin Lyrica Prednisone Percodan Neurontin Skelaxin Durgesic Topamax Flexeril Dilaudid Elavil Soma Demerol Trazadone Zanaflex Tylenol #3 Valium REVIEW OF SYSTEMS Indicate if you have experienced any of the following: CONSTITUTIONAL X EYES, EARS, NOSE, THROAT x Helpful Yes/No X RESPIRATORY X Weight gain- last 6 months Recent changes in vision Short of breathe Weight loss- last 6 months Recent changes in hearing Cough Night sweats Recent changes in smell Sputum Chills Recent changes in taste History of Tuberculosis Fever Dizziness Wheezing GASTROINTESTINAL GENITO-URINARY Central Nervous System Nausea Blood in urine Poor appetite Vomiting Urinary tract infection Problem sleeping Diarrhea Unable to control bladder Numbness/ tingling feet Indigestion Unable to control bowel Numbness/ tingling hands Abdominal Pain Rushing to go Crying spells Bloody or dark stools Need to go frequently Convulsions CARDIOVASCULAR MUSCULOSKELETAL SKIN Chest Pain Cramps Easy bleeding Palpitations Attack of weakness Any rashes Shortness of breath Joint pain/ Swelling Easy bruising Heart Murmur Feet Edema Morning stiffness PHYSICIAN SIGNATURE DATE 6
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
Samuel A. Joseph, Jr., M.D. In order to be seen by one of our physicians, you must bring the following to your visit:
Samuel A. Joseph, Jr., M.D. Your appointment has been scheduled: Your appointment time is: Please arrive at: o o o 2727 West Dr. Martin Luther King Jr. Blvd. Suite 590 Tampa, FL 33607 1840 Mease Drive
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
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:
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,
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
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 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
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
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:
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
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:
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
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
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
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Spine New Patient Questionnaire Rev
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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:
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SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
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
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Last Name First Name Middle Name MRN
Dr. Byers Dr. Su Dr. Sponzilli Lisa Elvin, NP Spine Center New Patient Form Last Name First Name Middle Name MRN This form is used to gather information so that my doctor can maximize the time used to
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
*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
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
Neurosurgery Clinic. I, hereby acknowledge, that I am not pregnant and understand the risks of having ionizing radiation. Date. Signature.
Name Chart # Neurosurgery Clinic I, hereby acknowledge, that I am not pregnant and understand the risks of having ionizing radiation. Date Signature X-ray Tech PATIENT INFORMATION FORM Name LAST FIRST
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
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
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Dr. Hall New Patient Paperwork Please fill out these forms completely
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NEW PATIENT INFORMATION SHEET
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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
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SPINE PROGRAM NEW PATIENT FORM
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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
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
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Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6
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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
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
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
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Last Name First Name MI: Address City State Zip. Referring Provider. Employer Address. Emergency Contact Relationship Phone. ID # Group # ID # Group #
Patient Demographic o New Patient o Return Patient o Update Account #: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave
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
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form
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NEW PATIENT INFORMATION FORM
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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
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
HISTORY PAPERWORK FOR APPOINTMENTS WITH DAVID A. PROPST, D.O.
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Spine Center New Patient Form
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MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History
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ASSIGNMENT OF BENEFITS
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Patient History Form
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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
Name: Sex: Male Female. Date of Birth: Occupation: Is this an accident or work related injury?
Name: Sex: Male Female Date of Birth: Occupation: Is this a 2 nd opinion? Yes No Is this an accident or work related injury? Please list: Family MD: Referring MD: Address: Address: Phone: Phone: Fax: Fax:
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CHIROPRACTIC ASSOCIATES CLINIC
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Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
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
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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:
Past Surgical History
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Primary Chief Complaint 1. Location 2. When did this begin? 3. How did this begin?
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Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
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?
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
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
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
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire Name: MR#:_ Date: Date of Injury: Referred By: Age: Date of Birth: Handed: R L Ambidextrous Male Female **** Mark
reasons for visit factors of complaint Date: Work comp injury Automobile accident Other injury
Date: LAST NAME FIRST NAME DATE OF BIRTH CURRENT AGE PRIMARY CARE PHYSICIAN PHONE NUMBER REFERRING PHYSICIAN PHONE NUMBER reasons for visit Work comp injury Automobile accident Other injury PRIMARY REASON