Preferred phone: Best time to call you: Morning Afternoon Evening

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Annice Henderson
5 years ago
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1 Page 1 of 7 Address: City: State: Zip: County: address: Phone Number: (Home) (Work) (Cell) Preferred phone: Best time to call you: Morning Afternoon Evening CONTACT INFORMATION Patients over 18 years old: If you are not present to receive a telephone call, may we leave a detailed voic message? Yes No May we leave a detailed message with someone else? Yes No If yes, with whom and what is his/her relationship to you? If patient is a Minor (<18 years old), please provide Parent s/legal Guardian s information: Parent/Legal Guardian #1 s name: Date of Birth: Same contact information as patient? Yes No If no, please provide below: Address: Home Phone: Cell Phone: Work Phone: Parent/Legal Guardian #2 s Name: Date of Birth: Same contact information as patient? Yes No If no, please provide below: Address: Home Phone: Cell Phone: Work Phone: Referring Physician Name and Primary Care Physician s (PCP) name: PCP *DT* *DT*

2 Other physicians followed on a regular basis: Connective Tissue Clinic Page 2 of 7 PATIENT S MEDICAL HISTORY 1. Has the patient already been diagnosed with a genetic condition? Yes No If yes, what specific condition? Name of physician who diagnosed the patient and type of physician? When was the patient diagnosed? 2. When did the patient s symptoms pertaining to this appointment first start, and what were those symptoms?

3 Page 3 of 7 3. What has been used to treat the patient s symptoms? 4. Has the patient ever had physical therapy? If so, for what? (If local, what facility?) HOSPITALIZATIONS DATE REASON SURGERIES DATE SURGEON/FACILITY PROCEDURE OUTCOME MEDICAL DIAGNOSES (applicable to the visit) DIAGNOSIS CURRENT TREATMENT GENETIC TESTING Please list any genetic testing that the patient has had done along with the results.

4 DIAGNOSTIC STUDIES/TESTS Connective Tissue Clinic Page 4 of 7 Please provide information regarding any other diagnostic studies/tests. STUDY DATE OF STUDY ABNORMALITIES/DIFFERENCES KNOWN ALLERGIES Please list allergen and corresponding reaction ALLERGY REACTION CURRENT MEDICATIONS MEDICATION DOSE FREQUENCY REASON FOR MEDICATION ROUTE (mouth, injection, eye drop, etc.)

5 Page 5 of 7 REVIEW OF SYSTEMS Please indicate if the patient has had any of the following issues: General Health Unexplained weight gain Unexplained weight loss Difficulty falling asleep Difficulty staying asleep Chronic fatigue How much & over what period of time? How much & over what period of time? Skin/Hair Slow wound healing Easy bruising Skin fragility Other skin/hair problems Specify: Head/Ears/Eyes/Nose/Teeth Ringing in the ears (tinnitus) Hearing problems Nearsightedness (myopia) Farsightedness (hyperopia) Other vision problems Wears glasses/contacts Narrow palate Braces/orthodontia Jaw pain/tmj

6 Page 6 of 7 Respiratory Shortness of breath Difficulty breathing Asthma Explain: Explain: Exercise induced or allergy: Cardiovascular Tachycardia Dizziness Fainting Exercise intolerance Gastrointestinal Hiatal hernia Reflux Constipation Irritable bowel syndrome Gastroparesis Diverticulitis/diverticulosis Nausea Abdominal Pain Blood in stool Genitourinary Urinary incontinence Bladder prolapse Endometriosis Blood/Lymphatic Anemia Bleeding tendency

7 Page 7 of 7 Musculoskeletal Hypermobility Joint dislocations Joint subluxations (popping) Joint pain Joint swelling Joint redness Osteoarthritis Fibromyalgia Scoliosis Neurological Migraine headaches Non-migraine headaches Psychiatric Depression Anxiety ADD or ADHD Specify: Signature of Patient/Parent/Legal Guardian Completing the Form: Printed Name of Patient/Parent/Legal Guardian Completing the Form: Relationship to Patient: Date:

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: ( ) 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: