THE WOUND HEALING CENTER at
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- Candace Poole
- 6 years ago
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1 THE WOUND HEALING CENTER at 350 Boulevard ǀ Passaic, NJ (973) Fax (973) NEW PATIENT INFORMATION FIRST NAME MIDDLE INITIAL HOME ADDRESS LAST NAME DATE OF BIRTH GENDER CITY STATE ZIPCODE SOCIAL SECURITY NUMBER PRIMARY PHONE Cell Work Home PHARMACY NAME, ADDRESS (or city), PHONE SECONDARY PHONE Cell Work Home ADDRESS HOW DO YOU WANT TO BE CONTACTED FOR APPOINTMENT REMINDERS? CALL ( ) TEXT PREFERRED LANGUAGE ARE YOU STAYING AT A REHABILITATION FACILITY? NO YES (facility name and city below please) HOW DID YOU HEAR ABOUT US? Where is your wound? When did it start? What is the story? What other physicians are treating you for this wound? H P I INSURANCE INFORMATION PRIMARY INSURANCE COMPANY SECONDARY INSURANCE COMPANY POLICY NUMBER POLICY NUMBER NOTES FOR OFFICE USE ONLY MR# Admission date to clinic: New to St. Mary s? Appointment MD: Case Mgr:
2 PAIN ASSESSMENT Are you in pain? no (skip this section) yes (mark the diagram and describe below) Current Pain Level: least worst Worst Pain Level: least worst Least Pain Level: least worst Tolerable Pain Level: least worst Is your pain: constant comes and goes PLEASE DESCRIBE YOUR PAIN ACHING DULL HEAVY SPLITTING THROBBING BURNING EASY TO SHARP STABBING TIRING PINPOINT CRAMPING EXHAUSTING SHOOTING TENDER OTHER: DIFFICULT TO PINPOINT PAIN MANAGEMENT AND MEDICATION: What helps you reduce or manage the pain Medication / NA Massage / NA Rest / NA T.E.N.S. / NA Activity / NA Other: / NA Apply Heat / NA Apply Cold / NA Is your current pain management working? Y / N How does your pain impact your daily activities? Sleep / NA Bathing / NA Appetite / NA Relationships with others / NA Bladder control / NA Emotions / NA Bowel Control / NA Work / NA Toileting / NA Driving / NA Dressing / NA Hobbies / NA What are your goals for managing your pain? Page 2 of 10
3 ALLERGIES to foods or medications Allergy to: What happens if you take or eat it? Severity MEDICATIONS Includes vitamins, supplements. You can also bring in the containers. MEDICATION or SUPPLEMENT STRENGTH (mg, ml etc) DOSE (how many tablets) FREQUENCY (how often) Page 3 of 10
4 REVIEW OF SYSTEMS: This is an overview of each part of your whole health picture. Do you have any of the following: General Health Skin Chills Change in hair, nails, skin Fatigue Dryness Fever Calluses / corns Loss of appetite Change in moles Weight up down: lbs in mos Purple or rusty discoloration of lower legs Night sweats Color changes to skin Other: Itching Lesions Eyes Lumps Blurred vision Open sore Dry eyes Prone to skin tears (cuts) Glasses / Contacts Rash Vision changes Ulcer Other: Other: Ear / Nose / Mouth / Throat Endocrine (Hormones) Dental problems Cold intolerance Hearing loss / aid Heat intolerance Nasal congestion Excessive thirst Painful or swollen lymph nodes Excessive urination Sore throat Other : Other: Muscles & Bones Respiratory (Lungs) Decreased activity Cough Joint pain Bloody phlegm Joint swelling Shortness of breath Assistive devices (cane, walker, braces ) Wheezing Backache Oxygen use Cannot straighten arm or leg Other: Deformities Muscle pain Cardiovascular (Heart) Muscle wasting (shrinking) Chest pain Muscle weakness Sweating Other: Difficulty breathing on exertion Swelling due to fluid collecting Blood & Lymph Leg pain while resting Bleeding or clotting disorders Swelling of lower legs Blood transfusion Shortness of breath when lying down Bruising Palpitations (fast heart beat) Other: Fainting Page 4 of 10
5 Gastrointestinal (stomach / gut) Neurologic (nerves) Acid reflux Abnormal walking Bowel incontinence Dizziness Change in bowel habits Headaches Constipation Numbness Diarrhea Paralysis Jaundice Seizures Loss of appetite Fainting Nausea / vomiting Tingling Stomach / belly pain Tremors Other: Weakness Other: Urinary Frequent urination Immunologic (defense) Pregnancy Frequent rashes Urgent urination (have to run!) Hay fever Urine leakage (can t hold it) Hives Other: Rhinitis Other: Psychiatric Anxiety Claustrophobia (can t be in small spaces) Depression Memory loss Nervousness / tension Suicidal Other: Page 5 of 10
6 PATIENT HISTORIES PAST MEDICAL HISTORY Condition Approx. month/year Comments PAST SURGERIES (include recent surgery relating to your current wound) Page 6 of 10
7 SOCIAL HISTORY Smoking Status: never smoked current every day current some days former smoker If current: how many packs per day for how many years? Marital Status: married single widowed divorced separated looking Children Occupation: Retired Veteran Service connected disability: Smokeless tobacco Electronic cigarettes Nicotine gum or patch Alcohol use: none social 1-2/day 4-5/day Substance abuse Illicit drug use Caffeine use Lives with: Receive homecare. If yes, how many hours per visit and how many days per week Assisted living Long-term care facility Skilled nursing facility Hospice care Independent Unable to care for self Need assistance with repositioning Need assistance with weight-shifting Need assistance with transfers Mental health concerns: Cultural, religious, or language concerns Object to blood products In counseling Financial concerns Transport concerns Support systems lacking Food, clothing or shelter needs Homeless Page 7 of 10
8 FAMILY HISTORY Your: Mother Mother s Parents Unknown History Bleeding Disorders Autoimmune Disease Cancer Diabetes Heart Disease Hereditary Spherocytosis High Blood Pressure Kidney Disease Lung Disease Malignant Neoplasm Of Skin Mental Illness Heart Attack (MI) Seizures Sickle Cell Anemia Stroke Suicide (including attempts) Tuberculosis Other Father Father s Parents Sibling Child Page 8 of 10
9 IMMUNIZATIONS Have you received: Refused No Yes If yes, approximate month/year Seasonal Influenza Shot Pneumonia Shot Hepatitis Shots Other: FALL RISK Have you fallen recently? no yes If yes, approximate month/year NUTRITION Has your eating declined over the past 3 months? If yes, have you: No Yes If yes, is it due to: lack of appetite digestive problems chewing problems swallowing problems you are trying to lose weight Lost Gained lbs over weeks or months ADVANCE DIRECTIVE - An advance health care directive, also known as living will, personal directive, advance directive, or advance decision, is a legal document in which you specify what actions should be taken for your health if you are no longer able to make decisions for yourself because of illness or incapacity. Do you have an advanced directive? Do you have a Do Not Resuscitate (DNR) order? If yes to any other the above, please bring us a copy. EDUCATION What level of education have you completed: What language do you prefer: Do you prefer to use an interpreter? no yes How do you learn best? Demonstration Explain/Verbal Video Written Do you have difficulty hearing? no yes What do you want to learn about? What can we help you understand? Page 9 of 10
10 ABUSE SCREENING Have you been touched when you did not want to be touched? Have you been forced to do something against your will? Have you been hit, struck, slapped, or kicked? Have you been yelled at or spoken to in a way that made you feel bad about yourself? Are you afraid of anyone? Are you being threatened? Has your money been used in a way you did not like? Have you given away anything when you did not want to? Do you have easy access to a phone? Do you have enough privacy in your home? Has anyone forced you to do things you don t want to do? Do you trust most of the people in your family? Has anyone taken, without your permission, things that belong to you? Do you have enough food, clothing, shelter, and medication available at all times? Can you leave your home when you want? Do you have the necessary aides such as dentures, cane, walker, hearing aid? Do you live with anyone or have any close family members who abuse drugs or alcohol, or have emotional/psychological condition? Do you take your own medication and/or get around by yourself? Have you recently felt down, depressed or hopeless? Have you noticed less interest or pleasure in doing things? Do you have thoughts of harming/killing yourself? Have you ever tried to hurt yourself before? Have you recently thought about harming or killing others? Page 10 of 10
INITIAL PATIENT FORM
Patient : INITIAL PATIENT FORM Reason for your visit: Visit Date: Left CIRCLE AREA(S) OF CONCERN: Right TOP/BOTTOM OUTSIDE INSIDE Type of pain: Sharp Burning Soreness Tightness Stabbing Numbness Aching
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PATIENT DEMOGRAPHICS PATIENT INFORMATION Patient: First Name Middle Initial Last Name Date of Birth SSN Gender: Male Female Address Email City State Zip Code Home Phone ( ) Cell Phone ( ) Occupation Employer
NEW PATIENT REGISTRATION FORM
NEW PATIENT REGISTRATION FORM (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Ethnicity: Hispanic Non-Hispanic Mr. Mrs. Ms. Miss Is this your legal name? If not, what is your legal
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
Cell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
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
Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol
PRE-EVALUATION FORM Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol High Blood Pressure Obesity Heart Defect
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
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
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex