Florida Hospital Spine Center Patient Intake Form

Transcription

1 Florida Hospital Spine Center Patient Intake Form Today s Date Last Name First Name Middle Street Address DOB (Address, City, State, Zip Code) First Contact # Please Circle: Home Cell Other Second Contact # Please Circle: Home Cell Other Social Security # Address: Spouse s Name Spouse s Contact # Nearest Friend or Relative (Name and Phone #) Primary Care Physician (Name and Phone #) Specialty Physician (Name, Phone # and Specialty) Preferred Language: Ethnicity: o Hispanic or Latino o Non-Hispanic or Latino o Declined Race: o American Indian/Alaska Native o Asian o White o Black/African American o Native Hawaiian/Pacific Islander o Other o Do Not Wish to Disclose Primary Insurance Company Phone # Insurance Company Address Insured Person s Name Insured Person s Social Security # Insured Person s DOB Relationship to Insured Person Group # Policy/ID # Copayment Amount Secondary Insurance Company Phone # Insurance Company Address Insured Person s Name Insured Person s Social Security # Insured Person s DOB Relationship to Insured Person Group # Policy/ID # Copayment Amount Is this an injury related to an auto/vehicular accident? Yes No Is this an injury related to a Worker s Compensation case? Yes No

2 Symptoms: Please place a check next to all the symptoms you have had in the past 6 months Constitutional Fatigue Body Aches Fever Weight Loss Chills Loss of Appetite Eyes Eye Pain Blurred Vision Floaters Visual Hallucinations Double Vision Peripheral Vision Changes Sudden Vision Loss Changes in Vision Transient Visual Loss Integument Rash Itching Hair Growth Change Gastrointestinal Nausea Constipation Heartburn Vomiting Loss of Appetite Diarrhea Difficulty Swallowing Abdominal Pain Endocrine Loss of Hair Heat Intolerance Constipation Decreased Libido Increased Libido Cold Intolerance Nipple Discharge Neurologic Muscular Weakness Difficulty Concentrating Seizures Falls Incoordination Memory Difficulties Tremors Head Injuries Tingling or Numbness Speech Difficulties Loss of Balance Ears, Nose and Throat Recent Head Injury Thyroid Mass Vertigo Sinus Pain Sore Throat Nasal Congestion Cardiovascular Chest Pain Syncope Lightheadedness Irregular Heart Beats Lower Extremity Edema Orthostatic Symptoms Rapid Heart Rate Claudication Respiratory Shortness of Breath Hoarseness Wheezing Cough Genitourinary Urgency Urinary Retention Impotence Frequency Difficulty Voiding Possible Pregnancy Incontinence Skipped Menstrual Cycle Psychiatric Anxiety Feeling Confused Depression Excessive Anger Heme-Lymph Easy Bleeding Lymph Node Enlargement Musculoskeletal Joint Pain Limitation of Motion Back Pain Joint Swelling Muscular Weakness Muscle Pain Muscle Cramps Neck Pain Other Difficulty Sleeping

3 Please explain any current symptoms not listed above : Do you have pain? Yes No If yes, where is your pain located? Does it r adiate? Yes No Describe your pain: Please Circle One Are you Right Handed or Left Handed? Right Left Ambidextrous Are you pregnant? Yes No Could you be pregnant? Yes No Current Height: Current Weight: Past Medical History: (Please check all applicable boxes) Anemia, Iron Deficiency Angina (Ischemic Chest Pain) Arthritis Asthma Bleeding Disorders Brain Mass: Intracranial Mass Cardiovascular Disease Congestive Heart Failure COPD Diabetes Gastric Reflux High Blood Pressure Hyperthyroidism Hypothyroidism Increased Cholesterol Irritable Bowel Syndrome Murmurs Peripheral Neuropathy Peripheral Vascular Disease Seizures Stroke Ulcers Fibromyalgia Gout Cancer (Please list details) Please explain all boxes checked above:

4 Past Surgical History : (please complete all applicable boxes) Past Tests/Treatments Yes/No Date Facility or Physician Physical Therapy Chiropractic Treatment EMG/Nerve Conduction Traction Epidural Injections Facet Blocks Facet Rhizotomies Trigger Point Injections Have you taken any NSAIDs (Non steroidal anti inflammatory medications like Advil, Aleve, Tylenol, etc.)? If so, please list: Please list all surgeries and major hospitalizations: (Date/Procedure) If none, please check o If spine related, have you seen a spine specialist in the past? Yes No If yes, physician name? Phone No. Have you previously seen a pain management doctor? Yes No If yes, physician name? Phone No. Medications: List name, strength, and how often taken. If none, please check o Medication (Prescription + Over the Counter Dose Frequency # Times/Day Reason/ Condition Treated Prescribing Doctor Current or Previous **Attach list if you need additional space

5 Family Medical History Please list and explain any family illness(es). Past Scans/Tests X-Rays MRI Sonogram Angiogram Fluid Analysis Bone Scan Vestibular Testing Date PET Scan CT Scan Nerve Tests Myelogram Cisternogram Laboratory Tests Date Date of Most Recent Scan: Facility: Do you have CD/Films? Yes No Social History Do you smoke? Yes No If so, how long have you smoked? How much do you smoke and how often? If you quit smoking, when did you quit? Do you drink alcohol? Never On Occasion Moderately Do you drink caffeinated beverages? Yes No Frequency: Daily Weekly Monthly