PRACTICE NAME NEW PATIENT MEDICAL HISTORY FORM. Chief Complaint. History of Present Illness
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1 PRACTICE NAME NEW PATIENT MEDICAL HISTORY FORM Height: Weight: Race: African American Asian Caucasian Native American/Alaskan Pacific Islander Other Unknown Decline to Answer Ethnicity: Hispanic Non-Hispanic Unknown Decline to Answer Preferred Language: English Spanish Chinese Other Preferred Pharmacy: Referral Source: Doctor (name): Other (ex. Google search): Chief Complaint Dominant Hand: Right Left Ambidextrous Description of Symptoms: (select only ONE primary symptom and ONE affected area) Pain Numbness/Tingling Fracture Stiffness Other: Shoulder Right Left Pelvis Right Left Neck Upper Arm Right Left Hip Right Left Upper Back Elbow Right Left Thigh Right Left Mid Back Forearm Right Left Knee Right Left Low Back Wrist Right Left Lower Leg Right Left Buttocks Hand Right Left Ankle Right Left Tail Bone Thumb Right Left Foot Right Left Index Right Left Great Toe Right Left Middle Right Left 2nd Digit Right Left Third Right Left 3rd Digit Right Left Little Right Left 4th Digit Right Left Pain radiates from/to: (ex. from low back to right leg) History of Present Illness 1. Is your problem the result of an injury or accident? 5th Digit Right Left No Injury Injury Injury at Work Auto Accident Sport Injury Prior Surgery How long have the symptoms been present? (ex. 2 days, 4 months) Describe the onset: Acute (sudden) Chronic condition (>3 months) Onset Date: (mm/dd/yyyy) 2. Are you represented by an attorney? Yes No Attorney Name: Will there be any legal actions with respect to this problem? Yes No 3. Have you had a problem like this before? Yes No Describe: 4. Have you been seen in an ER for this problem? Yes No Treating ER: (ex. St. Luke s Health) Date: (mm/dd/yyyy)
2 Page 2 History of Present Illness (continued) 5. Rate the pain (10 being the most pain): Do the symptoms wake you from sleep? Yes No 7. Please describe the symptoms: Sharp Dull Stabbing Throbbing Aching Burning Shooting 8. What is the timing of the symptoms? Constant Intermittent (comes and goes) 9. Is the problem getting better or worse? Getting better Getting worse Unchanged 10. What makes the symptoms worse? Squatting Kneeling Sitting Bending Stairs Twisting Moving Lying in bed Running Walking Athletics Standing Gripping Lifting Reaching Overhead 11. Are there any other symptoms associated with this problem? Redness Bruising Swelling Numbness Stiffness Limping Clicking Locking Popping Tingling Weakness Giving way Prior Testing / Treatment Have you had any prior tests for this problem? None X-rays MRI CT Scan Nerve Test (EMG/NCV) Bone Scan Have you had any prior treatment for this problem? Yes No Type of treatment Status of symptoms after treatment (select only those that apply) Date of treatment Ice Improved Worsened Unchanged Heat Improved Worsened Unchanged Rest Improved Worsened Unchanged NSAIDs Improved Worsened Unchanged Muscle Relaxers Improved Worsened Unchanged Chiropractor Improved Worsened Unchanged Physical Therapy Improved Worsened Unchanged HomeExerciseProgram Improved Worsened Unchanged Surgery Improved Worsened Unchanged Injections Improved Worsened Unchanged Bracing Improved Worsened Unchanged TENS unit Improved Worsened Unchanged Other/Comments:
3 Page 3 Select all previous hospitalizations/surgeries: None Aneurysm (Brain) Surgery Hysterectomy Orthopedic on side: Right Left Aortic Bypass / Vascular Surgery LAP Band / Gastric Bypass Surgery Arthroscopy: Knee Appendectomy Lumpectomy Arthroscopy: Shoulder Cataract (Eye) Surgery Mastectomy Carpal Tunnel Release Cholecystectomy (Gallbladder) Malignancy/Cancer Rotator Cuff Repair Heart Surgery Stents Total Hip Replacement Hernia Repair Total Knee Replacement Total Shoulder Replacement Spinal Surgery - Indicate Level: Other Surgery Other Orthopedic Surgery Medical Questions Mark all that currently apply: Metal in body Claustrophobic Pregnant Sleep Apnea Uses a CPAP Snores Are you taking blood thinners? Yes No Review of Systems Please indicate if you have experienced any of the following symptoms in the last 6 months? None for all None Comments 1) CON Weight Loss Loss of Appetite Fatigue 2) EYE Blurred Vision Double Vision Vision Loss 3) ENT Hearing Loss Hoarseness Trouble Swallowing 4) CV Chest Pain Palpitations 5) RS Chronic Cough Pneumonia Shortness of Breath 6) GI Heartburn, Ulcers Nausea, Vomiting Blood in Stool 7) GU Painful Urination Blood in Urine Kidney Problems 8) SK Frequent Rashes Skin Ulcers Lumps Psoriasis 9) NEU Frequent Falls Loss of Coordination Numbness Change in Bowel Change in Bladder Dizziness 10) PSY Depression/Anxiety Drug/Alcohol Addiction Sleep Disorder 11) ENDO Fever Heat or Cold Intolerance Night Sweats 12) HEM Easy Bleeding Easy Bruising Anemia
4 Page 4 Family History Have any direct relatives had any of the following disorders? None for all Father None Diabetes Heart Disease Hypertension Social History Do you smoke tobacco? Current, every day smoker Current, some day smoker Former smoker Never Pain Diagram Mother None Diabetes Heart Disease Hypertension Sibling None Diabetes Heart Disease Hypertension Heavy tobacco smoker Light tobacco smoker Do you drink alcohol? Daily Occasionally Rarely Never Marital Status: Married Single Divorced Widowed Domestic Partnership Are you currently working? Yes No Retired Disabled If no, what date did you last work? Please list work restrictions, if any: Occupation: Employer: Student
5 Page 5 Do you have any allergies? Yes No If Yes, please list below: Medication, Relevant Food, or Seasonal Reaction Latex allergy? Yes No Please list all medications you take on a regular basis: None Medication Dosage and Frequency (e.g. 20 mg, once/day) Do you have a personal history of any of the following? None Aneurysm Where: Emphysema Kidney Disease Angina (Chest Pain) Epilepsy Kidney Stones Arthritis Type: Heart Attack MRSA Infection Asthma Hepatitis Type: Pacemaker Bone or Joint Infections HIV / AIDS Phlebitis (Blood Clots) Cancer Type: High Cholesterol Pulmonary Embolism Chemotherapy / Radiation Hypertension Reaction to Anesthesia Type: COPD Hyperthyroidism Seizures Congestive Heart Failure Hypothyroidism Stomach Ulcers Diabetes Type: Last A1C: Stroke / TIA Tuberculosis Please list any other conditions or details of conditions marked above: Signature Date
NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE
NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE Today s : Patient Name: DOB: Race White/Caucasian Black/African American Asian Native American Alaskan Native Native Hawaiian Pacific Islander Other: Preferred Language:
NEW PATIENT INFORMATION FORM
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MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History
MEDICAL INFORMATION TODAY S DATE: SOCIAL SECURITY NUMBER: PATIENT NAME: BIRTHDAY: HEIGHT: WEIGHT: AGE: WHO REFERRED YOU? RACE: PRIMARY CARE PHYSICIAN: SEX: DOCTOR S ADDRESS: SECTION 1: Pharmacy Information
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
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HEALTH QUESTIONNAIRE
HEALTH QUESTIONNAIRE NAME AGE SEX: Male / Female DATE COMPLETED: OCCUPATION EMPLOYER HEIGHT WEIGHT BIRTHDATE DOMINANT HAND: Left / Right NAME OF YOUR PRIMARY CARE PHYSICIAN (INTERNIST OR PEDIATRICIAN):
Morris Medical Center, P.A.
Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~
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Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)
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Patient Information. Insurance Information
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Last Name First Name MI: Address City State Zip. Referring Provider. Employer Address. Emergency Contact Relationship Phone. ID # Group # ID # Group #
Patient Demographic o New Patient o Return Patient o Update Account #: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave
Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
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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
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
History of Present Problem
Patient Name: Date: If you are not the patient: Guardian name: Relationship to Patient: Height: Ft In Weight: lbs Age: Birth Date: Dominant Hand: Right Left Shoe Size: Primary Care Physician: Specialists:
California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)
California Chiropractic Boshears, Inc. 35191 Yucaipa Blvd., Yucaipa Ca. 92399 Phone: (909) 790-5005 Fax : (909) 790-5009 Patient Information Date: Name: Address: Home Phone: Work Phone: Sex: Male or Female
Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female
Place Patient Sticker Here Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female Social Security # Marital Status: Single Married Divorced Widowed Ethnicity: Non Hispanic
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D. PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC Name: Age: Sex: Male Female Occupation: Job description: Date: PLEASE ANSWER THE FOLLOWING QUESTIONS: Major
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
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: