New Patient Intake Form

Transcription

1 New Patient Intake Form Please complete information below Name: DOB Age Male Female Referring Physician FAX Address Phone _ Primary Care Physician FAX Address Phone Is this a work related problem? If yes, list your OWCP or L&I # If disabled, when did you last work? Is this a Motor Vehicle Accident related problem? Do you currently reside in a skilled nursing facility? Yes No If so where? From what dates? Chief Complaint: Right Left Both When did this problem begin (date of injury): Hand Dominance? Right Left How did it happen: Circle the symptoms that best describe your problem: Stiffness Pain Instability Numbness Swelling Other If you have pain, please circle the description that is most appropriate: Sharp Throbbing Aching Burning Stabbing Heavy Dull Circle the number corresponding to the intensity of your pain: (0 = no pain and 10 = the worst pain imaginable) How are your symptoms changing? Better Gradually Better Rapidly Worse Gradually Worse Rapidly Staying the Same Circle what improves your symptoms? Rest Ice Heat NSAID Splinting Massage Other Circle what worsens your symptoms? Activity Cold Pressure Other What studies or treatments have you had for this problem? (Circle all that apply) X-rays CT MRI Nerve study (EMG) Arthrogram Bone Scan Surgery

2 Social History What is your height and weight? Height in feet and inches Weight in pounds _ Do you smoke? If yes, how much of a pack per day? How many years have you been smoking? Were you previously a smoker? Yes No If yes, when did you quit and how long did you smoke for? Do you have any children? If so how many children? Do you drink alcohol? Do you drink caffeine? If yes, how many drinks per week? If yes, how many drinks per week? Do you following a specific diet? If yes, which diet? Have you ever had a drug or alcohol problem? If yes, please specify Work status? Employed Unemployed Disability Student Retired Homemaker Occupation Do you exercise? Highest level of education If yes, how many times per week? What type of exercise? Marital Status? Single Married Divorced Separated Widowed Domestic partner Personal Medical History Please circle if you have a history of any of the following, Allergies Anxiety Asthma Bipolar Bleeding Disorder Cancer Chronic Lung Disease Coronary Artery Disease Congestive Heart Failure Depression Diabetes DVT/Clotting Disorder Fibromyalgia Heart attack Heartburn/reflux Hepatitis (specify type) High Blood Pressure High cholesterol Kidney Disorder Liver Disorder Neck Fusion Psoriasis Rheumatoid Arthritis Sleep Apnea Stroke Thyroid Disorder Other Family History Please circle if any of your family members have had the following, PLEASE SPECIFY WHICH FAMILY MEMBERS (Indicate maternal or paternal when applicable) Diabetes High Blood Pressure Stroke Heart attack Cancer Depression Arthritis _ Kidney/ Liver Disease Autoimmune Rheumatoid DVT/Clotting Disorder Gout Other Bleeding Disorder

3 Surgeries: (Please circle all that applies) No previous surgeries Appendix (appendectomy) Gall bladder (cholescystectomy) By-pass/open heart (CABG) Hernia repair Hysterectomy Tonsils removed (tonsillectomy) C-Section Surgical History Year Other surgeries Procedure Year L or R Allergies Please circle if you have any of the following allergies and specify your reaction No Known Drug Allergies Erythromycin Codeine Iodine Penicillin Others: Sulfa Latex Current Medications: Dose: Times per day: Reason you are taking *OR ATTACH LIST OF MEDICATIONS Review of Systems General (weight gain/loss, fatigue, insomnia, fever/chills) Eyes (glasses/contacts, cataracts, glaucoma) Ear/Nose/Throat (sinus trouble, hearing loss) Heart (chest pain, high blood pressure, coronary artery disease, irregular heartbeat) Lungs (shortness of breath, asthma, lung disease) Stomach (heartburn, nausea, diarrhea, hepatitis) Muscle / Bones (joint pain, muscle pain, arthritis, fractures, sprains) Urinary Tract (painful urinating, kidney stones, prostate) Skin (masses, blisters, dermatitis, eczema) Neurologic (seizures, numbness/tingling) Mental Health (anxiety, depression) Endocrine (frequent urination, excessive thirst, diabetes, hypothyroid) Hematological (bleeding/clotting problems, anemia, swollen lymph nodes) Allergic / Immunologic(HIV/AIDS, hay fever lupus) Yes No Comments

4 New Problem Intake Form Please complete information below Name: DOB Age Male Female Referring Physician FAX Address Phone _ Primary Care Physician FAX Address Phone Is this a work related problem? If yes, list your OWCP or L&I # If disabled, when did you last work? Is this a Motor Vehicle Accident related problem? Do you currently reside in a skilled nursing facility? Yes No If so where? From what dates? Chief Complaint: Right Left Both When did this problem begin (date of injury): Hand Dominance? Right Left How did it happen: Circle the symptoms that best describe your problem: Stiffness Pain Instability Numbness Swelling Other If you have pain, please circle the description that is most appropriate: Sharp Throbbing Aching Burning Stabbing Heavy Dull Circle the number corresponding to the intensity of your pain: (0 = no pain and 10 = the worst pain imaginable) How are your symptoms changing? Better Gradually Better Rapidly Worse Gradually Worse Rapidly Staying the Same Circle what improves your symptoms? Rest Ice Heat NSAID Splinting Massage Other Circle what worsens your symptoms? Activity Cold Pressure Other What studies or treatments have you had for this problem? (Circle all that apply) X-rays CT MRI Nerve study (EMG) Arthrogram Bone Scan Surgery

5 Please note any information regarding history, medications and allergies that may have changed since your last visit Social History What is your height and weight? Height in feet and inches Weight in pounds _ Do you smoke? If yes, how much of a pack per day? How many years have you been smoking? Were you previously a smoker? Yes No If yes, when did you quit and how long did you smoke for? Do you have any children? If so how many children? Do you drink alcohol? If yes, how many drinks per week? Do you drink caffeine? If yes, how many drinks per week? Do you following a specific diet? If yes, which diet? Have you ever had a drug or alcohol problem? If yes, please specify Work status? Employed Unemployed Disability Student Retired Homemaker Occupation Highest level of education Do you exercise? If yes, how many times per week? What type of exercise? Marital Status? Single Married Divorced Separated Widowed Domestic partner Personal Medical History Please circle if you have a history of any of the following, Allergies Anxiety Asthma Bipolar Bleeding Disorder Cancer Chronic Lung Disease Coronary Artery Disease Congestive Heart Failure Depression Diabetes DVT/Clotting Disorder Fibromyalgia Heart attack Heartburn/reflux Hepatitis (specify type) High Blood Pressure High cholesterol Kidney Disorder Liver Disorder Neck Fusion Psoriasis Rheumatoid Arthritis Sleep Apnea Stroke Thyroid Disorder Other Family History PLEASE SPECIFY WHICH FAMILY MEMBERS (Indicate maternal or paternal when applicable) Diabetes Depression Arthritis High Blood Pressure _ Kidney/ Liver Disease Autoimmune Stroke Rheumatoid DVT/Clotting Disorder Heart attack Gout Other Cancer Bleeding Disorder Surgical History Allergies to Medications or Substances (e.g., particularly eggs or chicken products, latex): Current Medications:

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9 ` A Division of Authorization to Leave Detailed Medical Messages Including Voic , In-Person, or Other Authorized Forms of Communication To an adult(s) age 18 or over only Incomplete or illegible forms will not be processed Purpose: Allow BBJP/OIMA patients the opportunity to receive detailed information regarding their individual healthcare treatment, insurance, billing or other information relevant to their relationship with OIMA. Patient Last Name (Print) Patient First Name (Print) Date of Birth MRN # (office use only): Authorization to Leave Detailed Medical Telephone Messages Including Voic , In-Person, or Other Authorized Forms of Communication This document authorizes BBJP/OIMA the right to leave detailed medical messages related to specific medical information regarding test results, patient instructions, follow-up care descriptions, medication refill status, referrals or billing and insurance information. Restrictions (if applicable): I hereby authorize BBJP/OIMA staff, physicians, and representatives to leave detailed medical messages at the following telephone numbers: *Telephone #1: * Telephone #2: Conditions of Authorization: * Indicates that telephone numbers above should belong to an adult 18 or older. 1. I understand that authorization may be granted only to individuals age 18 or over. 2. I understand that authorization does not include obtaining copies of electronic or written medical records. 3. I confirm that OIMA has explained the limitation and restrictions that apply to this process. 4. I understand that detailed messages may not be left with me despite my authorization if determined to be in my best interest. 5. I understand that I am fully responsible for reporting changes to the phone numbers that I have provided. 6. I understand that authorization is effective on date of signature and does NOT expire until I revoke this authorization in writing. 7. I understand that this written authorization may be revoked at any time by writing the Privacy Officer at OIMA. My signature below represents my voluntary request to make the above assignments and my full legal authority to do so. Patient s Printed Name Patient s Authorized Signature Date of Signature OSDC-DMM form Rev. 02/16