Please indicate where your present pain level is by circling the number that best describes the intensity: No Pain Mild Moderate Severe
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- Anabel Pearson
- 5 years ago
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1 Date: Specific Date of Onset: Please indicate where your present pain level is by circling the number that best describes the intensity: No Pain Mild Moderate Severe Your insurance company may inquire as to how your pain/dysfunction is currently interfering with your daily activities. Please 1) Indicate specific activity limitations that you have currently. You may report in minutes, hours, distance, etc. for activities limited at this time. If a listed activity is not limited leave blank. You may add activities under recreational activities and other. 2) Please list any activities that you had limitations with prior to the onset of this occurrence of pain, injury or surgery in area titled Limitations prior to this problem. 1. Current: How much/long Can t Do How much/long Can t Do before limiting? before limiting? Standing Bathing Sitting Eating Walking Dressing Stairclimbing Using toilet Sleeping Writing Driving Computer work Lifting Combing/ To waist Fixing hair Lifting Reaching back overhead pocket Bending to Housekeeping Tie shoes Opening Doors Turning car Applying makeup Ignition Or shaving Opening Other (list): Containers Recreational Activities: 2. Prior Limitations prior to this problem: Therapist Use Only: History reviewed by Therapist Date MacHD:private:var:folders:UO:UOWyG3+y2RWrek+8ZPglwU+++TQ:TemporaryItems: bnt.doc
2 Please complete all pages of the following questionnaire, as this will assist your therapist in evaluating you. Should you need assistance, please ask the office staff. If you do not fill out this questionnaire, the therapist will have to spend your evaluation time completing it with you. Thank you! Name Date R L hand dominant Age: If less than 18 years old: Height: Weight: 1. What is your reason for attending therapy? 2. Please use the diagram at the right to show your location of pain/problem in the last 24 hours. Use a P to mark pain and an N to mark numbness and/or tingling: 3. My specific goals upon completion of therapy are: (how will you know you are better?) 4. Have you had an accident/injury related to this problem? no yes If yes, please describe: _ Front Back 5. When did your problem/pain begin (date; mm/dd/yy if possible): a. If more than 6 months, have you had a recent flare up of your symptoms, please explain and give date: b. Frequency /Duration: Constant Frequent Occasional c. How would you describe your pain? Not Applicable Sharp Dull Burning Other 6. What symptoms did you first notice: 7. What activities or positions increase your complaints? 8. What activities or positions decrease your complaints? 9. Are your complaints getting: Better Worse Staying the same? 10. Have you had this problem before? no yes, please explain: 11. Any difficulties with bowel or bladder function related to this problem? No Yes, please explain 12. Any dizziness or unsteadiness on your feet? No Yes, explain 13. Does coughing/sneezing aggravate your complaint? No Yes, explain MacHD:private:var:folders:UO:UOWyG3+y2RWrek+8ZPglwU+++TQ:TemporaryItems: bnt.doc
3 14. Do you have any difficulty swallowing? no yes, please explain: 15. Check any previous treatments for this problem: Physical Therapy Social Service Support Group Dietary Consult Speech Therapy First Steps Occupational Therapy Splinting Surgery (date) Chiropractic Injection Other 16. Any X-rays, MRI, CT, EMG, etc. taken related to your current problem? yes no If yes, results (include date and where taken) 17. Are you currently working? yes no unemployed with limitation on disability Comment/restrictions given by doctor: 18. Is there a Workman's Comp. or lawsuit pending regarding your problem? yes no comment Name of Workman's Comp. Caseworker 19. Occupation: What does your job involve: % Sitting; circle all that apply: computer, assembly line, desk work % Driving; type of vehicle: % Standing; surface: % Lifting; range of weight lifted: Number of times per hour: From to (heights) % Other: 20. Past History of Injuries/Accidents: Past Surgical History: Year Description Year Description 21. Other Medical: Have you ever been diagnosed with any of the following conditions? Associated Medication Arthritis No Yes, Date/Comment: Osteoporosis No Yes, Date/Comment: Cancer No Yes, Date/Comment: Heart disease No Yes, Date/Comment: Diabetes No Yes, Date/Comment: Circulation problems No Yes, Date/Comment: Chemical dependency (i.e. drug, alcohol, etc.) No Yes, Date/Comment: Stomach disorders No Yes, Date/Comment: Lung disease No Yes, Date/Comment: Thyroid disease No Yes, Date/Comment: Hepatitis No Yes, Date/Comment: Kidney/bladder disease No Yes, Date/Comment: Skin disease No Yes, Date/Comment: Epilepsy No Yes, Date/Comment: High blood pressure No Yes, Date/Comment: Female/Male diseases No Yes, Date/Comment: Neurological No Yes, Date/Comment: Depression No Yes, Date/Comment: Are you pregnant? No Yes, Date/Comment: Other No Yes, Date/Comment: MacHD:private:var:folders:UO:UOWyG3+y2RWrek+8ZPglwU+++TQ:TemporaryItems: bnt.doc
4 22. List any additional medications or alternative medicines you are currently taking (over the counter & prescription): 23. Please list any allergies (including allergy to Latex): 24. Have you ever reacted to the following when handling, or after eating, avocados, bananas, tropical fruit, pineapple, kiwi, nectarines, peaches, cherries, chestnuts, poinsettia plants, balloons, elastic bandages or rubber products? yes no 25. Do you have, or have you had in the past; eczema on your hands, unexplained anaphylaxis (acute extreme shortness of breath, cardiac arrest or shock-sudden drop of blood pressure), or did you have multiple surgical procedures during infancy? yes no 26. Have you been on cortisone/prednisone? No Yes, when? 27. Do you Smoke? No Yes, how much? _ 28. Do you drink caffeine? No Yes, how much? 29. Do you drink alcohol? No Yes, how much? 30. Why did you choose this facility for your service? (Check all that apply) Reputation of Clinic Insurance Requirement My physician's recommendation Location Friend's or family's recommendation Other: 31. I desire to learn : (Check all that apply) exercises injury prevention ergonomics (fit the job to the person) posture correction additional resources that may help me 32. I prefer to learn in the following ways: demonstration verbal instruction video written material 33. Difficulty with writing? yes, related to this problem yes, unrelated to this problem no comment Difficulty with reading? yes no comment 34. My primary language is: English Spanish other 35. Check current or prior conditions that you may have or had: language impairment emotional disorder mental disorder; type vision impairment cognitive disorder communicative disorder hearing impairment physical impairment developmental disabilities Comments: 36. When is your next doctor s appointment for this problem? 37. Did your doctor give you any limitations regarding this problem? If yes, please list/explain: 38. Is there any other information you feel might be helpful for the therapist to know before your evaluation? If yes, please explain: MacHD:private:var:folders:UO:UOWyG3+y2RWrek+8ZPglwU+++TQ:TemporaryItems: bnt.doc
5 Therapist Comments: MacHD:private:var:folders:UO:UOWyG3+y2RWrek+8ZPglwU+++TQ:TemporaryItems: bnt.doc
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Date: WELCOME TO: Name: Address: Patient Information Last First MI Street City State Zip Phone # : (Mobile) (Home) (Work) Can we leave a voicemail or text message? Yes No Email: Date of Birth: Gender:
Carriage House Chiropractic and Acupuncture
Chiropractic Patient History Questionnaire Date: Name: Date of birth: Address: City: St: Zip: Phone: (home) (cell) (work) May we send appointment reminders to you via text messages on your cell phone Email:
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,
Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S. Chiropractic Care
Basic Information Full Name: Address: City: State: Zip: Cell: Home: Work: Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S Email: Occupation: Emergency Contact: Phone: Children: O No
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight:
NUMBNESS EVALUATION FORM Date: Name: Last First Initial Date of Birth SS # - - Age: Dominant Hand: Right Left Height: Weight: I Referring Doctor Complete Name of Referring Doctor Last Complete Address
Back and Neck Pain Questionnaire
www.orthonc.com Back and Neck Pain Questionnaire Please print legibly in black ink. Answer only questions applicable to your condition. Leave other spaces blank. Date you are filling out this form: PERSONAL
Occupation: Leisure Activities: ALLERGIES Are you latex-sensitive? Y N List any medication(s) you are allergic to:
Hello and thank you for choosing Fusion Physical Therapy as the provider for your current healthcare need(s)! We look forward to working with you to help make your day a little easier! To ensure you receive
SPARROW FAMILY CHIROPRACTIC
Whom may we thank for referring you to this office? SPARROW FAMILY CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS PM#: Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail Address:
Family First Chiropractic
Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of Birth / / Sex: Male Female
DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)
1275 Olentangy River Rd. Ste 120 Columbus, Ohio 43212 Telephone (614) 291-5555 Fax: (614) 291-7720 Dr. David B. Kaplansky Dr. Randall Contento PATIENT Dr. INFORMATION Garrett Kalmar FORM www.columbusohiopodiatrist.com
Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week
3 Washington Circle W, #207/208 Patient ame: Age: Chief Complaint: Please describe what you are being seen for today: What is your hand dominance (which hand do you write with)? Left Right Ambidextrous