PATIENT INJURY/MEDICAL HISTORY FORM
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- Caren Ross
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1 PATIENT INJURY/MEDICAL HISTORY FORM Name Date Date of Loss/Onset (Accident): Claim Number: _ Describe Accident: Specifics of Accident (Mark each that applies to the accident): Job or Work Related injury ( ) Yes ( ) No Immediately Following the Accident Your were the [ ] Driver [ ] Passenger [ ] Ambulance Paramedics Called Sitting [ ] Front seat [ ] Back seat [ ] Treated at Scene [ ] Transported to Hospital by Ambulance Impending Collision [ ] Braced [ ] Not braced [ ] Went to Hospital on his/her Own Head Did [ ] Strike Object [ ] Not strike Object [ ] Diagnostics Preformed at Hospital Did you experience [ ] Shock [ ] Medication Prescribed [ ] Flash of Light Seen Upon Impact [ ] Treatment at Hospital [ ] Air bag Deployed [ ] Follow-up Recommended Time Loss [ ] NO time loss from work due to injury. I am currently working with No limitations. [ ] NO time loss form work due to injury BUT I do have limitations*. [ ] I have experienced time loss from work due to injury. Indicate number of days, weeks, months etc [ ] N/A Additional Comments: ******************************************************************************************************* Mechanism of Injury Were you surprised by the impact? In relation to the back of your head, was your headrest set: Where was your head facing at the time of impact? Were you leaning forward at the time of impact? Were you wearing a seatbelt/harness? Were you rendered unconscious as a result of the accident? Did you feel pain immediately after the accident? Low Middle High None Left Forward Right Unknown Year and type of vehicle were you in? Size of your vehicle? Small Mid Large Unknown Year and type of other vehicle involved in the accident? Size of other vehicle? Small Mid Large Unknown What was the approximate speed of your vehicle when the accident occurred? What was the approximate speed of the other vehicle when the accident occurred? 1
2 Patient s Name: Date: PAIN FORM Symptomatology Consultation Form Pain Intensity: Intensity scale: 0 = No pain 1 3 = Mild Nuisance 4 5 = Mild to Moderate Nuisance 6-7 = Moderate, having trouble dealing with it 8-10 = Severe, it is affecting patient s quality of life WHERE DID YOU HURT BEFORE THE ACCIDENT Symptoms prior to most recent motor vehicle collision: WHERE DID YOU HURT IMMEDIATELY AFTER THE ACCIDENT Original symptoms from most recent motor vehicle collision: WHERE ARE YOU HURTING TODAY Presenting/Current Symptoms: 2
3 What makes current pain worse: Describe directly below for example (bending, sitting) Headaches: Jaw Pain: Neck Pain: Middle Back Pain: Low Back Pain: What makes current pain better: Headaches: Jaw Pain: Neck Pain: Middle Back Pain: Low Back Pain: Achy Burning Dull Sharp Throb Other Worse in AMorPM Further Pain information: Radiating Pain/Numbness/Tingling/Burning/Weakness Yes No Location ********************************************************************************************** Social History List your Hobbies & Exercise Activities [ ] Single [ ] Smoker [ ] Married [ ] Non-Smoker [ ] Divorced [ ] Drinks Alcohol Number of Children: [ ] Does not drink Alcohol [ ] Takes Drugs [ ] Does not take Drugs Occupational History Your Employer What is your current job satisfaction: [ ] Very Satisfied Job Title [ ] Satisfied [ ] Dissatisfied Are your Job Duties Physically demanding for you? [ ] Yes [ ] No [ ] Very Dissatisfied Have you had any disability time? [ ] Yes [ ] No If you are currently working which are you performing? Your highest level of education attained? [ ] Regular Duties [ ] Limited Light Duties ******************************************************************************************************* 3
4 Name Date Medical History Form 1 I have seen the following physician/practitioners for this condition: Chiropractor (Name): Massage Therapist: Neurologist: Orthopedist: Physical Therapist: Physician: Psychiatrist/Psychologist: Do you feel you are troubled with: [ ] Anxiety [ ] depression [ ] irritability Current medications I am taking: List the treatments you have had for this condition. Past Surgeries: [ ] Ice [ ] Chiropractic [ ] Heat/Ultrasound [ ] Osteopathy [ ] Electrical Stimulation [ ] Injections [ ] Exercises [ ] Acupuncture [ ] Gravity Inversion Traction [ ] Naturopathy [ ] Bed Rest [ ] Massage Past Hospitalizations: _ List previous back, neck and musculoskeletal problems: **************************************************************************************************** Name Date PATIENT INJURY/MEDICAL HISTORY FORM 2 List the types of Diagnostic Testing that has been for this condition: [ ] X-rays [ ] Discogram [ ] CT Scan [ ] Bone Scan [ ] Myelogram [ ] EMG [ ] MRI Females Mark if have the following: [ ] Vaginal bleeding other than period [ ] Pap smear within last two years [ ] Painful menstrual periods [ ] Back pain with menstrual periods [ ] Other menstrual problems 4
5 Name Date Mark if you have had any of the following symptoms in the past 5 years: [ ] Unexplained fevers [ ] Swollen ankles [ ] Night sweats [ ] Stomach pain [ ] Weight loss of 10 lbs or more [ ] Change in bowel habits [ ] Loss of appetite [ ] Persistent diarrhea [ ] Excessive fatigue [ ] Excessive constipation [ ] Problems with depression [ ] Dark black stools [ ] Difficulty sleeping [ ] Blood in stools [ ] Unusual stress at work [ ] Pain-burning when urinating [ ] Unusual stress at home [ ] Difficulty urinating start / stop [ ] Easy bruising [ ] Blood in urine [ ] Excessive bleeding [ ] Need to urinate more at night [ ] Lumps in neck, armpit or groin [ ] Morning stiffness [ ] Chest pain or tightness [ ] Persistent eye redness [ ] Persistent or unusual cough [ ] Muscle tenderness [ ] Trouble breathing with exercise [ ] Dry eyes or mouth [ ] Trouble breathing lying flat [ ] Skin rashes [ ] Coughing up blood [ ] Joint pain or swelling Make sure to fill out the neck pain disability index questionnaire and/ or Oswestry low back pain questionnaire in addition. 5
Intro to the Office. four years of pre-chiropractic college education in the biological sciences, followed by another four
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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Zindt Chiropractic Center 3819 S M St Workmen s Compensation Tacoma, WA 98418 Information Name Date Date of Birth Last Name First Name Middle Initial Employment Information Employer s business name (at
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit)
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit) Last name: First Name: Title: Mr. Mrs. Dr. Appt Date: Refer by: (Please provide name
NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
Creekside Chiropractic
Creekside Chiropractic ---- - New Patient History Date: Name: Home Phone: Cell Phone: Social Security #: Birthdate: Age: Email Address: Street Address: City: State: Zip: Please circle the best way to contact
WESTERN NEUROSURGICAL CLINIC MEDICAL EVALUATION QUESTIONNAIRE. Name: Date of Birth. Age: Social Security No.: Driver's Lic.# Occupation: Employer:
Date: IDENTIFICATION: WESTERN NEUROSURGICAL CLINIC MEDICAL EVALUATION QUESTIONNAIRE Name: Date of Birth Age: Social Security No.: Driver's Lic.# Occupation: Employer: ******************************************************************************
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
SANTA MONICA BREAST CENTER INTAKE FORM
SANTA MONICA BREAST CENTER Who referred you to see us today? Who is your primary care physician? Are there any other MDs who you would like to receive today s visit information? No Yes MD contact info
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
Welcome to our office!
Welcome to our office! Today s Date / / Patient Title: Mr. Mrs. Ms. Miss Dr. Name: Preferred Name: Address: City: State: Zip Code: Home Phone: Work Phone: Mobile Phone: Email Address: Preferred Contact
Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
Name: Age: Date: Accompanied by Relationship E-mail: @ MEDICAL BACKGROUND INFORMATION Please name the professionals that you have seen for this condition: Name Specialty Town Phone Who is your primary
Personal Injury Questionnaire. Name: Address: City: State: Zip: Cell Phone: Home phone: Work Phone: Social Security Number:
Personal Injury Questionnaire Name: Address: City: State: Zip: Cell Phone: Home phone: Work Phone: Social Security Number: Email: Date of birth Sex: Male Female Marital States S M D W Date of Accident: