FOR SECURITY REASONS, WE DO NOT ALLOW OCCUPIED VEHICLES IN OUR PARKING LOT.
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- Ralf Greer
- 5 years ago
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1 Pain & Wellness of Centers of Georgia FOR SECURITY REASONS, WE DO NOT ALLOW OCCUPIED VEHICLES IN OUR PARKING LOT. I understand that if I receive a ride here, the people that accompany me MAY NOT wait in the parking lot. I may bring one guest inside with me while I am here, but any additional guest must leave and come back to pick me up once I am COMPLETELY finished with my doctor s appointment. Meaning AFTER I have seen the doctor and checked out. Patient s Name: Patient s Signature: Date:
2 Pain & Wellness Centers of Georgia 4905 LaVista Road Tucker, Georgia General Information Date: - - Patient Name: (Last Name) (M. I.) (First Name) Social Security: - - Date of Birth: - - Gender: Male or Female Street Address: City: State: Home Phone: - - Zip: Cell Phone: - - Emergency Contact: Emergency Contact: Home Phone: - - Cell Phone: - - Relationship: Medical History: Location of pain: Duration of pain: How did the pain start: Have you ever been to a pain clinic in the past: Are you currently seeing and receiving medical treatment for your current condition? If yes please explain treatment and why you are here to see us: Patient Signature: Date:
3 Pain & Wellness Centers of Georgia 4905 LaVista Road Tucker, Georgia INFORMATION ABOUT YOUR PRIMARY PAIN PROBLEM 1. What is your main reason/primary diagnosis for coming to the clinic today? 2. How long have you had the pain? 3. Which of the following best describes how the pain began: Check all that apply. Accident at home Accident at work Work Related Motor vehicle accident After surgery After an illness Just began Came on gradually o Other: 4. How do you best describe your pain? Dull ache Shooting Burning Sharp Throbbing Other: 5. Do you have any of the following with you pain? a. Tingling/numbness in the hands/feet Yes No b. Weakness in the hands/feet Yes No c. Pain radiating to arm/hands/forearms Yes No d. Pain radiating to thigh/buttock/leg/feet Yes No e. Dragging the foot while walking Yes No f. Difficulty holding bladder or bowels Yes No 6. Do you need to use any of the following to walk or support since the pain started? Cane Walker Crutches Braces 7. Which affects your pain? Mark B for Better 7 W for Worse; leave blank if there is not effect. Massaging or rubbing Coughing Strong emotions Standing Sudden movement Anxiety Getting out of bed Running Noise Heat Sitting Bright light Cold weather Lying down walking Bending Vibration Ice Physical Therapy Straining Wet climate Fatigue Reaching Lifting Other:
4 Treatment you have tried: 8. List all surgical procedures that you have had. Use separate sheet if needed. Procedure Part of the Body Date 9. Have you ever attended Chronic Pain management program? Yes No If Yes, Where? When? (Year) INFORMATION ABOUT YOUR MEDICAL HISTORY 10. Please check any of the following that you have had within the past 6 months: Anxiety attach Feeling tired/low energy Painful sex/intercourse back pain Headaches racing/pounding heart Bloated Joint pain Seizures Chest pain Loss of consciousness Low mood Sleep problems Shortness of breath Diarrhea or constipation Dizziness Loss of memory Trouble walking Easy bleeding Vision Nausea/Vomiting Painful menstruation Fainting spells/blackouts Other : 11. Have you ever received mental health treatment? Yes No If Yes, When and for what condition: 12. Do you have any allergies? Yes No If Yes, Please list all known allergies: 13. Do you have any blood relatives (immediate family) with a history of any of the following? Alcoholism Depression Headache Suicide Chronic pain Disability Mental Illness Other: (Please specify):
5 INFORMATION ABOUT YOUR MEDICATIONS 14. Present Medications: List all prescribed and over-the-counter medications (Tylenol, Aspirin, etc.), nutritional supplements, herbal remedies, ad homeopathic remedies you are currently taking. Please include medications for pain, sleep, chronic conditions, etc. Medication Dosage/ day Side effects (if any) How effective 15. PAST: List medications (include over-the-counter, herbal and homeopathic) taken in the past. Use additional sheet of paper if you need more space to answer pain medication questions. Medication Dosage/ day Side effects (if any) Why discontinued CONCLUSION: Additional comments or more information about current or past pain medications, pain treatments, or surgical procedures for pain
6 Social History 1. Who are you currently living with? (circle as many that applies) Live alone Spouse/partner Parents Roommate Children; ages 2. Describe your home situation (who does most of the chores) 3. Are you currently experiencing any stressful situations? (circle the one that applies) Martial/relationship stress Stress at work Financial stress Stress with your family Stress with your friends INFORMATION ABOUT YOUR HABITS 1. In a typical week, how many days do you get exercise? days 2. In a typical week, how many days do you drink alcohol? days 3. In a typical day, how many drinks do you have? (number of drinks) (1 drink= 12 ounce can of beer, 4 ounces of wine, or a 1 ounce shot of hard liquor). 4. Have people upset you by criticizing your drinking or drug use? 5. Have you ever felt you should cut down on your drinking or drug use? 6. Have you ever participated in a substance abuse treatment program? 7. Do you use tobacco? (cigarettes, cigars, chewing tobacco, pipe, nicotine replacement) If Yes, amount per day Number of years 8. Do you drink regular coffee, tea, colas or other caffeinated drinks?
7 If Yes, how much per day? (number of drinks) (ounces/drink) 9. Do you use street drugs or drugs not prescribed by your doctor? Marijuana Cocaine Methamphetamine Heroin Other INFORMATION ABOUT YOUR SLEEP 1. Trouble falling asleep because of pain? a. Never b. 1-2 times/week c. 3-5 times/week d. 6-7 times/week 2. Wake up in the night because of pain? a. Never b. 1-2 times/week c. 3-5 times/week d. 6-7 times/week 3. How long does it take to return to sleep? 4. How often do you need medication to fall asleep? a. Never b. 1-2 times/week c. 3-5 times/week d. 6-7 times/week 5. What sleep medications do you take? (include over-the-counter medications) 6. In general, how many hours of sleep for you get per night? 7. How many hours of sleep do you need to feel rested? 8. Do you take daytime naps? Psychological History Over the last 2 weeks, how often have you been bothered by any of the following problems? (circle all that applies)
8 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling asleep 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself 7. Trouble concentrating on things 8. Moving or speaking slowly 9. Thoughts that you would be better off dead 10. Thoughts of hurting others Patient Name: Patient Signature: Date: - -
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Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
ACUPUNCTURE SPECIFIC INTAKE FORM
ACUPUNCTURE SPECIFIC INTAKE FORM A naturopathic approach to medicine is holistic and seeks to understand all factors that may be affecting your health. Please answer the following questions to the best
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
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
problems/medications: Current supplements/vitamins/herbs: Past medical problems/medications: Other doctors/clinics seen regularly:
Main Purpose of the consultation (Please give a brief summary of the main problems) What happened to make you seek evaluation at this time? MEDICAL HISTORY Current medical Prior Attempts to correct the
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
Name: Sex: Male Female. Date of Birth: Occupation: Is this an accident or work related injury?
Name: Sex: Male Female Date of Birth: Occupation: Is this a 2 nd opinion? Yes No Is this an accident or work related injury? Please list: Family MD: Referring MD: Address: Address: Phone: Phone: Fax: Fax: