Patient Health History and Information
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- Nigel Richards
- 5 years ago
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1 Patient Health History and Information Date: Age: Height: Weight: Sex: M F Dominant hand: R L Could you be or are you pregnant: Y N Reason for Therapy: Date of injury/onset of symptoms: / / Please describe how your injury/problem occurred (i.e. fall, activity, work, auto, unknown): Recent surgery? Yes No Date: / / Type: Please list any treatment you have received for this condition (i.e. Therapy, Chiropractor): For this condition have you had any of the following? None X-ray / / MRI / CT scan / / Injection: type: / / Surgery: type: / / Other: / / Using the key below indicate on the body diagrams where your symptoms are located. X=Pain //= Numbness O=Tingling Please rate your pain (0=none, 1=minimal, 10=severe) At present: At worst: At best: Please describe your pain/symptoms Which side are we seeing you for?: Right Left What makes your symptoms worse? (i.e. heat, cold, rest) What makes your symptoms better? (i.e. heat, cold, rest) Please indicate your current limitations due to injury: Laying down Bending Sleeping: Going from sit to stand Work Sitting: Up / Down stairs Driving Walking: Squatting Swallowing Standing: Looking overhead Turning head Reaching: Taking a deep breath Self care / Hygiene Repetitive activities Constant Intermittent Increasing Decreasing Talking / Chewing / Yawning / All (circle one) Staying the same Sharp Dull Aching Burning Weakness Throbbing Other: Home activities Sports / Recreation Other: Since your symptoms began have you had any of the following: Fever / Chills Yes No Unexplained weight change Yes No Nausea / Vomiting Yes No Night sweats / pain Yes No Numbness genital/anal area Yes No Problems with vision / hearing / speech Yes No Dizziness / Fainting Yes No Difficulty with bowel/bladder function Yes No Unexplained weakness Yes No Other: Yes No Headaches Yes No Med Hx pg. 1 of 3 09/15/2017
2 Who referred you to Physical Therapy? Primary Physician: How did you hear about PTOSI Physical Therapy? Physician Friend/relative Website Previous patient Self Coach Other What are your goals for therapy? GENERAL HEALTH HISTORY: Have you had any falls or near falls in the past year? Yes No Rate your overall health: Excellent Good Average Poor Do you exercise? Yes No x/week Do you smoke? Yes No Do you drink caffeinated beverages? Yes No /week Occupation/job title: Self Student Full time Part time Retired Unemployed Living Situation: Alone Spouse Family Others Physical activities at work: Sitting Standing Computer use Phone use Repetitive/Heavy lifting Other: Employer: Current work duty: Full duty Restricted duty Work days missed: QRC (if you have one): Have you or anyone in your immediate (brother, sister, parent, grandparent) family ever been diagnosed with any of the following: Allergies/asthma Self Family No Kidney problems Self Family No Cancer Self Family No Thyroid problems Self Family No High blood pressure Self Family No Epilepsy/dizziness Self Family No Heart trouble/angina Self Family No Tuberculosis Self Family No Diabetes Self Family No Anemia/blood disorder Self Family No Stroke Self Family No Multiple Sclerosis Self Family No Osteoporosis Self Family No Circular/vascular problems Self Family No Osteoarthritis Self Family No Chemical dependency Self Family No Rheumatoid arthritis Self Family No Pace maker/metal implants Self Family No Depression Self Family No AIDS/HIV Self Family No Headaches Self Family No Hepatitis Self Family No Bladder/bowel problems Self Family No Other: Self Family No Over the past 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest in the pleasure of doing things: 0- Not at all 1- Several days 2- More than half the days 3- Nearly every day 2. Feeling down, depressed or hopeless: 0- Not at all 1- Several days 2- More than half the days 3- Nearly every day Are there any other issues/concerns that you think we should know about that may or may not effect your ability to benefit from physical/occupational therapy treatment: Yes No Patient Signature: Date / / Reviewed by Therapist: Date / / MD follow-up: / / None Scheduled With-in 90days of last Medical history completion (date and initial any changes) Medical History reviewed by patient, changes noted and reviewed by therapist. Patient Signature: Date / / Reviewed by Therapist: Date / /
3 TMD Disability Index Questionnaire Please check the one statement that best pertains to you (not necessarily exactly) in each of the following categories. Section 1 - Communication (Talking) (0) I can talk as much as I want without pain, fatigue or discomfort. (1) I talk as much as I want, but it causes some pain, fatigue and/or discomfort. (2) I can't talk as much as I want because of pain, fatigue and/or discomfort. (3) I can't talk much at all because of pain, fatigue and/or discomfort. (4) Pain prevents me from talking at all. Section 2 - Normal Living Activities (Brushing Teeth/Flossing) (0) I am able to care for my teeth and gums in a normal fashion without restriction, and without pain, fatigue or discomfort. (1) I am able to care for all my teeth and gums, but I must be slow and careful, otherwise pain/discomfort, jaw tiredness results. (2) I do manage to care for my teeth and gums in a normal fashion, but it usually causes some pain/discomfort, jaw tiredness no matter how slow and careful I am. (3) I am unable to properly clean all my teeth and gums because of restricted opening and/or pain. (4) I am unable to care for most of my teeth and gums because of restricted opening and/or pain. Section 3 - Normal Living Activities (Eating, Chewing) (0) I can eat and chew as much of anything I want without pain/discomfort or jaw tiredness. (1) I can eat and chew most anything I want, but it sometimes causes pain/discomfort and/or jaw tiredness. (2) I can't eat much of anything I want, because it often causes pain/discomfort, jaw tiredness or because of restricted opening. (3) I must eat only soft foods (consistency of scrambled eggs or less) because of pain/discomfort, jaw fatigue and/or restricted opening. (4) I must stay on a liquid diet because of pain and/or restricted opening. Section 4 - Social/Recreational Activities (Singing, Playing Musical Instruments, Cheering, Laughing, Social Activities, Playing Amateur Sports/Hobbies, and Recreation, etc) (0) I am enjoying a normal social life and/or recreational activities without restriction. (1) I participate in normal social life and/or recreational activities but pain/discomfort is increased. (2) The presence of pain and/or fear of likely aggravation only limits the more energetic components of my social life (sports, exercising, dancing, playing musical instrument, singing). (3) I have restrictions socially, as I can't even sing, shout, cheer, play and/or laugh expressively because of increased pain/discomfort. (4) I have practically no social life because of pain. Section 5 - Non-Specialized Jaw Activities (Yawning, Mouth Opening and Opening my Mouth Wide) (0) I can yawn in a normal fashion, painlessly. (1) I can yawn and open my mouth fully wide open, but sometimes there is discomfort. (2) I can yawn and open my mouth wide in a normal fashion, but it almost always causes discomfort. (3) Yawning and opening my mouth wide are somewhat restricted by pain. (4) I cannot yawn or open my mouth more than two finger widths ( cm) or, if I can, it always causes greater than moderate pain. Page 1 Total:
4 TMD Disability Index Questionnaire Section 6 - Sexual function (Including Kissing, Hugging and Any and All Sexual Activities to Which You Are Accustomed) (0) I am able to engage in all my customary sexual activities and expressions without limitation and/or causing headache, face or jaw pain. (1) I am able to engage in all my customary sexual activities and expression, but it sometimes causes some headache, face, or jaw pain, or jaw fatigue. (2) I am able to engage in all my customary sexual activities and expression, but it usually causes enough headache, face or jaw pain to markedly interfere with my enjoyment, willingness and satisfaction. (3) I must limit my customary sexual expression and activities because of headache, face or jaw pain or limited mouth opening. (4) I abstain from almost all sexual activities and expression because of the head, face or jaw pain it causes. Section 7 - Sleep (Restful, Nocturnal Sleep Pattern) (0) I sleep well in a normal fashion without any pain medication, relaxants or sleeping pills. (1) I sleep well with the use of pain pills, anti-inflammatory medication or medicinal sleeping aides. (2) I fail to realize 6 hours restful sleep even with the use of pills. (3) I fail to realize 4 hours restful sleep even with the use of pills. (4) I fail to realize 2 hours restful sleep even with the use of pills. Section 8 - Effects of Any Form of Treatment, Including, But Not Limited to, Medications, In-office Therapy, Treatment, Oral Orthotics (eg, Splints, Mouthpieces), Ice/Heat, etc. (0) I do not need to use treatment of any type in order to control or tolerate headache, face or jaw pain and discomfort. (1) I can completely control my pain with some form of treatment. (2) I get partial, but significant, relief through some form of treatment. (3) I don't get "a lot of" relief from any form of treatment. (4) There is no form of treatment that helps enough to make me want to continue. Section 9 - Tinnitus, or Ringing in the Ear(s) (0) I do not experience ringing in my ear(s). (1) I experience ringing in my ear(s) somewhat, but it does not interfere with my sleep and/or my ability to perform my daily activities. (2) I experience ringing in my ear(s) and it interferes with my sleep and/or daily activities, but I can accomplish set goals and I can get an acceptable amount of sleep. (3) I experience ringing in my ear(s) and it causes a marked impairment in the performance of my daily activities and/or results in an unacceptable loss of sleep. (4) I experience ringing in my ear(s) and it is incapacitating and/or forces me to use a masking device to get any sleep. Section 10 - Dizziness (Lightheaded, Spinning and/or Balance Disturbance) (0) I do not experience dizziness. (1) I experience dizziness, but it does not interfere with my daily activities. (2) I experience dizziness which interferes somewhat with my daily activities, but I can accomplish my set goals. (3) I experience dizziness, which causes a marked impairment in the performance of my daily activities. (4) I experience dizziness, which is incapacitating Total Score Total # Possible = % Disability Page 2 Total: Total Score ( Page 1 + Page 2): Patient Signature: Therapist Signature: Date Date
5 Jaw Functional Limitation Scale 20 For each of the items below, please indicate the level of limitation during the last month. If the activity has been completely avoided because it is too difficult, then circle 10'. If you avoid an activity for reasons other than pain or difficulty, leave the item blank. No limitation Severe limitation 1. Chew tough food 2. Chew hard bread 3. Chew chicken (e.g., prepared in oven) 4. Chew crackers 5. Chew soft food (e.g., macaroni, canned or soft fruits, cooked vegetables, fish) 6. Eat soft food requiring no chewing (e.g., mashed potatoes, apple sauce, pudding, pureed food) 7. Open wide enough to bite from a whole apple 8. Open wide enough to bite into a sandwich 9. Open wide enough to talk 10. Open wide enough to drink from a cup 11. Swallow 12. Yawn 13. Talk 14. Sing 15. Putting on a happy face 16. Putting on an angry face 17. Frown 18. Kiss 19. Smile 20. Laugh
6 1. In order to provide optimal care it is important for us to maintain an up-to-date list of all your medications. 2. Please fill out the chart below. **If you already have a complete list of your medications, please bring it and we will make a copy in lieu of completing this form. Allergies/Adverse effects to medications: Name of prescription medication (brand or generic) Dosage Why are you taking this medication? How often do you take it? How do you take it? (by mouth, injection, etc.) Example: Lasix 20 mg. High blood pressure Two times a day By mouth Over the Counter medication or nutritional supplements Dosage Why are you taking this medication? How often do you take it? How do you take it? (by mouth, injection, etc.) Patient Signature: Date: a Patient updated: Date: Therapist reviewed: Date: a Therapist reviewed: Date:
Patient Health History and Information
Patient Health History and Information Date: Age: Height: Weight: Sex: M F Dominant hand: R L Could you be or are you pregnant: Y N Reason for Therapy: Date of injury/onset of symptoms: / / Please describe
Patient Health History and Information
Name: Patient Health History and Information DOB: Date: / / Age: Height: Weight: Dominant hand: R L Could you be or are you pregnant: Yes No Sex: M F Reason for Therapy: Please describe how your injury/problem
Subjective Medical History Information
Page 1 of 8 Date: Patient Account #: Patient Name: Insurance: Date of Birth: History of current condition 1. Which of the following best describes how your injurt occurred? (if your injury is post-surgical
PATIENT HEALTH HISTORY
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Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE
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ASSIGNMENT OF BENEFITS
ASSIGNMENT OF BENEFITS PATIENT NAME: First Middle Last PHONE NUMBER: Home: Work: HOME ADDRESS: City ZIP AGE: DOB: SSN: Status EMAIL ADDRESS: PATIENT EMPLOYER: How long? Occupation SPOUSE S EMPLOYER: Spouse
\ NSMI. The National Sports Medicine InstJtute
~ \ NSMI The National Sports Medicine InstJtute 19455 Deerfield Avenue Su ite 3 12 Lansdowne, Virgin ia 20 I76 24430 Stone Spring Blvd, Suite 250, Dulles, Virginia 20166 Patient Information: Last Name:
Spine New Patient Questionnaire Rev
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PLEASE BRING COMPLETED PACKET TO APPOINTMENT ALONG WITH YOUR FILMS
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DR. MOSCOW & ASSOCIATES PATIENT INFORMATION
DR. MOSCOW & ASSOCIATES PATIENT INFORMATION Name Date / / Sex: Male Female Date of Birth Age Cell Phone ( ) Home ( ) Work ( ) Email address Preferred Method of contact Social Security # Address City State
PAIN MANAGEMENT IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.
PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and REPORTS of any X- rays, MRI or Cat scans. Patient s name:
CHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
Re-Exam Questionnaire
Re-Exam Questionnaire Patient Name: Date: The following hi-lighted symptoms are what brought you into our office originally. DIRECTIONS: Please rate ALL hi-lighted symptoms: S = same; B = better; W = worse
APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male
ACTIVE EDGE CHIROPRACTIC
ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Email: Occupation: Birth
COMPREHENSIVE HEALTH & WELLNESS PROFILE
Patient Name DOB COMPREHENSIVE HEALTH & WELLNESS PROFILE The human body is designed to be healthy. Throughout life, events occur which damage your natural health expression. As a full spectrum Chiropractic
REFERRED BY PAINFUL SIDE: RIGHT, LEFT, CENTRAL, RIGHT MORE, LEFT MORE, EQUAL ON BOTH SIDES, OTHERS DAILY PAIN: HRS MIN TIMES DAYS, WEEK, MONTH
NAME ADDRESS PHONE AGE DOB / / HT WT RACE MALE FEMALE SSN DATE OF ACCIDENT: / / REFERRED BY DATE OF VISIT CIRCLE APPROPRIATE ANSWERS OR EXPLAIN: 1. TYPE OF INJURY AUTO WORK OTHER PLEASE GIVE DETAILED EXPLANATION
CHIEF COMPLAINT(S) Please mark area(s) of injury or discomfort on the diagrams below.
CHIEF COMPLAINT(S) Please mark area(s) of injury or discomfort on the diagrams below. Please describe your current primary complaint? Difficulty in: Standing, Sitting, Bending, Walking, Reaching Cannot
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM First Name MI Last Preferred Name Date of Birth / / Age Gender Patient/Guarantor SS# - - Email Address Martial Status Single Married Other Street Address City State Zip Code Profession
Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)
Patient s Name: Date: What is the reason for your visit today? Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone #
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
BRIEF PAIN INVENTORY LONG FORM
BRIEF PAIN INVENTORY LONG FORM Date: Name: 1) Marital Status (at present) Single Widowed Married Separated/Divorced 2) Education (Circle only the highest grade or degree completed) Grade 0 1 2 3 4 5 6
Employed? Yes No Employer Name. Occupation. Problem Onset Frequency Severity E.g. Headaches June times per week Mild / Moderate / Severe
PLEASE NOTE: This file must be saved to your desktop before and after completing! PATIENT INFORMATION Date First Name SSN Sex Marital Status Middle Name Birth Date Last Name Height Spouse Name Address
MOTOR VEHICLE ACCIDENT PAIN CHART
MOTOR VEHICLE ACCIDENT PAIN CHART Name Today s Date (D/M/Y) Area of Concern What is the WORST pain you have ever experienced? (other than the pain you are experiencing NOW!) What was the date of this painful
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?
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
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Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
GENERAL INFORMATION HISTORY QUESTIONNAIRE Name: Today s Date: Age: Date of birth: Sex: M F SS#: Home Address: Cell Phone: Your doctor: Home Phone: Your Attorney (if any): If questions arise after today
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.