Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?
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1 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 HCFA) Page: 1 Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: Height: Weight: I. What are you being seen for today? II. Which side is affected? O Right O Left O Bilateral III. Date of Injury or start of pain: How did the pain occur? O Injury O Chronic O Spontaneous Is this work related? O Yes O No Is this the result of a motor vehicle accident? O Yes O No IV. Pain Description Quality of your pain? O Mild O Moderate O Severe Type of pain? O Sharp O Dull O Other: Have you had physical therapy? O Yes O No Are you taking any pain medications? Anti-inflammatory agent O Yes O No Drug Name: Pain Medication O Yes O No Drug Name: Tylenol O Yes O No Have you been putting ice on the area? O Yes O No Have you had any testing? O MRI O EMG/NCS O Bone Scan O CAT Scan Are you? O Left handed O Right handed
2 Page: 2 Do you have or have you had: Medical History Asthma/ COPD O Yes O No Cancer O Yes O No Diabetes O Yes O No High Blood Pressure O Yes O No Acid Reflux Disease O Yes O No Heart Attack O Yes O No Osteoporosis O Yes O No Hypertension O Yes O No Emphysema O Yes O No Seizures O Yes O No Stroke O Yes O No Arthritis O Yes O No Gout O Yes O No Thyroid Disease O Yes O No Kidney Problems O Yes O No Blood Clots O Yes O No Social History Marital status: O Single O Married O Widowed O Divorced Do you smoke? O Yes O No O Previously If yes, How many packs/ day? O <1 O 1-2 O >2 How many years have you smoked? O 1-4 O 5-10 O >11 Do you consume alcohol? O Yes O No In the past did you consume alcohol? O Yes O No
3 Page: 3 How often do you consume alcohol? O Daily O Social O Never Do you exercise regularly? O Yes O No Working Status: O Full time O Part Time O Student O Unemployed Family History Father O Arthritis O Cancer O Diabetes O Stroke O Heart Trouble O Lung Disease Mother O Arthritis O Cancer O Diabetes O Stroke O Heart Trouble O Lung Disease Siblings O Arthritis O Cancer O Diabetes O Stroke O Heart Trouble O Lung Disease Grandparents O Arthritis O Cancer O Diabetes O Stroke O Heart Trouble O Lung Disease Review of Systems Are you experiencing any of these issues now? Constitutional: Fatigue O Yes O No Weight change O Yes O No Fever O Yes O No Neurological: Headache O Yes O No Numbness/ Tingling O Yes O No Seizures O Yes O No Dizziness O Yes O No Coordination Problems O Yes O No Neck Pain O Yes O No Respiratory: Shortness of Breath O Yes O No Chest Pain O Yes O No Trouble Breathing O Yes O No Wheezing/ Asthma O Yes O No Chronic Coughing O Yes O No
4 Page: 4 Coughing up Blood O Yes O No Cardiovascular: Chest Pain O Yes O No Irregular Heartbeat O Yes O No High Blood Pressure O Yes O No Leg/Ankle swelling O Yes O No Spine: Severe Back Pain O Yes O No Curvature of the Spine O Yes O No Back Problems O Yes O No Musculoskeletal: Joint pain O Yes O No Joint stiffness O Yes O No Joint swelling O Yes O No Back Pain O Yes O No Gastrointestinal: Nausea/ Vomiting O Yes O No Stomach Ulcer / Reflux O Yes O No Diarrhea O Yes O No Blood in stool O Yes O No Skin: Rashes/sores O Yes O No Skin Cancer O Yes O No Itching/ Burning O Yes O No Hematological: Anemia O Yes O No Easy Bruising O Yes O No Bleeding problem O Yes O No Women Only: Are you, or could you possibly be pregnant? O Yes O No
5 Page: 5 Medications (Please list name and dosage): Allergies (Please list): Surgeries (Please list name and year): Patient Signature Date
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail 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
*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
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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
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
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:
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
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
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Page 1 of 6 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Race Select
AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION
Medical Record # Patient Name(s) Date of Birth Social Security # Contact Phone # AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION OBTAIN FROM: (Releasing facility) RELEASE TO: (Receiving entity)
Patient Name Date of Birth Age. Other phone ( ) . Other
GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight: