PATIENT INFORMATION. Last Name: First Name: Address: City/State/Zip: Phone: (H): (W): (C): Date of Birth: Gender: Male Female
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1 PATIENT INFORMATION Date Last Name: First Name: Address: City/State/Zip: Phne: (H): (W): (C): Date f Birth: Gender: Male Female EMERGENCY CONTACT INFORMATION Last Name First Name Middle Initial Phne Number(s): Nearest Relative/Friend Nt Living With Yu: Phne Number(s): Abve infrmatin will be used fr verificatin and emergency purpses nly. Hw did yu hear abut RestraLife? Referral Physician Friend Patient TV Cmmercial (News 13) Space Cast Business Internet Search/Website Seminar Attended Indian River Fitness Carrabba s Newspaper Article Insert Bareft Tattler Facebk Calilu / PC Keat s Bran s Saving Safari Mail Insert Senir Scene Glf Scre Card 304 S. Harbr City Blvd. Suite 100. Melburne FL [] (321)
2 PATIENT HEALTH QUESTIONNARE Please list all peratins yu have had: Medicatins: Previus treatment fr cnditins: Current Primary Care Physician: Physician Cntact Phne Number: Have yu ever been treated by a pain center? If yes, please list dctr. D yu smke? If s, hw much? _ D yu drink alchl? If s, hw much? _ D yu use recreatinal drugs? If s, hw much? _ Please list all drug allergies (medicatins, inhalants, fds, cntact allergies): Please describe any ther prblem which may nt have been cvered abve and which yu wuld like the clinician t knw: 2
3 Patient Name: Mark the areas where yu are experiencing pain. Please circle the amunt f pain yu are in: 0 (n pain) t 10 (severe pain) N Pain Wrst Pain PRIMARY prblem* that brught yu t RestraLife? SECONDARY cmplaints* r areas f pain? 3
4 * Please label n the diagram abve the primary and secndary areas f pain Head and Neck Altered sense f smell Nasal bstructin Snring Nasal discharge Nsebleeds Facial Pain Lcal skin lesins that have changed recently Lumps r swelling Eyes Duble visin/blurred visin Dry eyes Itchy/watery eyes Glaucma Flashing lights Flaters Retinal prblems Are yur eyes matted/dry in the a.m.? Respiratry System Chrnic cugh Wheezing, asthma Histry f TB r lung cancer Allergies _ Neurlgic Headaches Transient lss f visin Seizures Strkes Head injury Anxiety r depressin _ 4
5 Cardivascular System Heart Murmur Chest Pain Swelling f the ankles Shrtness f breath n exertin Heart surgery r angiplasty High bld pressure _ Endcrine Diabetes Over r underactive thyrid _ Urgenital Frequent urinatin Prstate prblems Kidney Disease Gastrintestinal Heartburn r Ulcers Jaundice, Liver Disease, Hepatitis _ General Skin Cancer Skin Diseases Bleeding Disrder Previus bld transfusin Bld clts Have yu ever been n Acutane? Have yu ever had cld sres? 5
6 Are yu a candidate fr Laser Therapy? Laser therapy is an FDA-cleared mdality fr the treatment f pain and inflammatin. The therapy causes a temprary increase f micrcirculatin. Increased micrcirculatin and the reductin f inflammatin can prvide relief fr many acute and chrnic cnditins. This frm is a tl t help yur clinician determine if yu are a candidate fr laser therapy. If yu answer yes t any f these questins yu will need t discuss details f yur cnditin with yur clinician. Please check r t the questins belw D yu have a pacemaker r any ther implanted devices? Are yu pregnant? D yu have cancer? Are yu taking medicatins that may increase yur sensitivity t light? Have yu had a sterid injectin in the last 7 days? Nt related t Laser Therapy: D yu have any knwn allergies r sensitivities t DMSO (Dimethyl Sulfxide)? (Stem Cell Patients Only) D yu have any knwn allergies t prducts frm birds such as feathers, eggs and/r pultry? (HA Patients Only) Patient signature: Date: Printed Patient Name: Ntes: 6
Patient Information Packet Date:
Patient Infrmatin Packet Date: We knw paperwrk is nt fun, but thank yu s much fr taking the time! Last Name: First Name: MI Address: Phne: City State: Zip Cde: Mbile: D.O.B: / / Scial Security: / / Email:
Urology CHIEF COMPLAINT ALLERGIES. What is the main reason for your visit today? Allergen Yes No Reaction
Urlgy Kari White, NP Phne: 646-962-9600 Name: Date f Birth: Date: CHIEF COMPLAINT What is the main reasn fr yur visit tday? ALLERGIES Are yu allergic t any f the fllwing? Please check YES r NO fr each.
Pediatric Health History Form
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Medical History. Yes or No
Medical Histry Althugh dental persnnel primarily treat the area in and arund yur muth, yur muth is a part f yur entire bdy. Health prblems that yu may have, r medicatin that yu may be taking, culd have
New Patient Registration and Medical History. Address City State Zip code
Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
New Patient Registration and Medical History. Address City State Zip code
Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719 2441 / Fax (724)719 2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
Patient Health History
Patient Health Histry Name: Date f Birth: Age: SS #: Tday's Date: Sex: Male Height: Female Primary Care Physician: Phne Number: Referring MD: Phne Number: Other MD's: Name/Specialty Pharmacy Name: Pharmacy
New Patient Information Sheet PLEASE COMPLETE THIS ENTIRE FORM. Date of Appointment: / /
New Patient Infrmatin Sheet PLEASE COMPLETE THIS ENTIRE FORM The frm may seem lengthy but it is very imprtant t help us understand yur pain cmplaints. This will help us prvide yu with the highest level
Patient Health History
Patient Health Histry Name: Date f Birth: Age: SS #: Tday's Date: Sex: Male Height: Primary Care Physician: Phne Number: Referring MD: Phne Number: Other MD's: Name/Specialty Pharmacy Name: Pharmacy Number:
PRIMARY COMPLAINT When did your pain start?
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The Allergy and Asthma Center f Crpus Christi 1718 Braeswd Dr, Crpus Christi TX 78412 text: 361-992-8500 Fax: 361-992-6711 www.allergycrpustx.cm NEW PATIENT FORMS FOR ADULT Patient Last Name First Name
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Address: City: State. Phone: (Home) (Work): (Cell): Age Date of Birth / / Occupation. Referred by: Patient s condition: Duration of Problem:
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Welcme t A very warm welcme t yu! The entire team wuld like t thank yu fr selecting ur ffice t care fr yur dental needs. We are a family-riented dental practice lcated n the suthwest crner f Furteen Mile
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