PATIENT REGISTRATION
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- Charles Walker
- 5 years ago
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1 PATIENT REGISTRATION Please complete this form as fully as possible to assist us in your evaluation and treatment. Please read each question carefully and answer to the best of your ability. This information is part of your medical record and is governed by our Privacy Practices Policy. PERSONAL INFORMATION Last Name: First Name: Middle Initial: Sex: Male Female Date of Birth: Social Security #: Height: Weight: Race: Circle Marital Status: Married Single Divorced Widowed Separated Domestic Partner Home Phone: Work Phone: Cell Phone: May we leave messages on your answering machine? May we send text reminders to your cell phone? Address: What is your preferred method of communication? Personal Representative: Phone: Emergency Contact Name: Relationship: Home Phone: Work Phone: Cell Phone: Do you have an Advance Medical Directive? If so, please bring a copy to the office. Employer: Phone: Occupation: Primary Care Physician: Phone: Referring Physician: Phone: Have you seen any other healthcare provider in the past 60 days? If yes, who? The following individual is authorized to pick up prescriptions on my behalf: Contact Name: Relationship: Page 1 of 8
2 PATIENT QUESTIONNAIRE PAIN HISTORY Reason for Your Visit. Briefly describe your pain: Duration. When did your current pain problem begin (date)? Onset. Under what circumstances did your pain first begin? Accident at work, date: Following surgery Accident at home Following an illness Auto accident Unknown Sports injury Other: Briefly describe the circumstance(s) you checked: Describe the speed of onset of your pain: Sudden/abrupt Gradual Severity. On a scale of 1 to 10, grade your pain. At its worst: At its best: At this moment: 0 = no hurt 1-2 hurts a little bit 3-4 hurts a little more 5-6 hurts even more 7-8 hurts a whole lot 9-10 hurts Location. Mark on the drawings the areas where you feel pain: Frequency. How often do you have this pain? Occasionally Constantly Daily Weekly Monthly What time of day is your pain worst? Morning Afternoon Evening Night What time of day is your pain the least? Morning Afternoon Evening Night Page 2 of 8
3 PAIN HISTORY - CONTINUED The questions below refer only to your current pain problem. Character. Circle the words that best describe what your pain feels like: Aching Gnawing Throbbing Stabbing Sharp Dull Burning Other: Cause. Circle the words that best describe the context/cause of your pain: Unknown Sitting Standing Walking Bending Twisting Lifting A-traumatic Fall Overuse Work injury Home injury Auto injury Assault Other: Alleviating Factors. Circle the words that best describe what makes your pain better: Nothing Sitting Standing Walking Stretching Exercise Position change Lying down Heat Ice Brace Wheelchair TENS unit Chiropractic care OTC medications/narcotics Other: Aggravating Factors. Circle the words that best describe what makes your pain worse: Unknown Sitting/driving Standing Walking Bending Twisting Lifting Carrying Pushing Pulling Exercise Weight bearing Lying down Getting out of bed Upstairs Downstairs Sit-to-stand Computer use Changing clothes Previous surgery Cough/sneeze Cold weather Damp weather Other: Associated Signs and Symptoms. Circle the words that best describe your associated signs and symptoms: Weakness Numbness Tingling Swelling Redness Warmth Radiation into limbs Catching Locking Buckling Grinding Instability Popping/clicking Fever Chills Rash Weight loss Bladder/bowel dysfunction Other: Diagnostic Testing. Circle the tests performed for this problem, if any, and state the approximate dates: X-ray film CT scan MRI Myelogram Bone scan EMG Blood tests Date: Date: Date: Date: Date: Date: Date: Previous Treatment. NSAIDs: Physical therapy: Home exercise: Chiropractic care L-spine: How long? Outcome? How long? Outcome? How long? Outcome? How long? Outcome? Effects on Activities of Daily Living. Circle the areas of your life that have been adversely affected by your pain: Sleep Appetite Relationships Work Finances Physical activity Use of alcohol Use of recreational drugs Other: Page 3 of 8
4 PAST SURGICAL HISTORY Please list all prior surgeries and hospitalizations: Date (month/year): Procedure/illness: PAST MEDICAL HISTORY Please circle any of the following medical conditions you have had or presently have: COPD Arthritis Hernia Diabetes Asthma High cholesterol GERD (reflux, frequent heartburn) Cancer High blood pressure Hepatitis Depression Kidney disease Addiction/substance abuse Migraines Mental illness Anxiety Heart disease Renal disease Memory loss Thyroid disease Other: FAMILY MEDICAL HISTORY Please circle any of the following medical conditions any of your BLOOD relatives have had or presently have, and indicate the relationship and whether the relationship is PATERNAL or MATERNAL: DIAGNOSIS RELATIONSHIP TO YOU PATERNAL OR MATERNAL COPD Diabetes Addiction/substance abuse Arthritis Asthma Bleeding disorder Cancer Chronic pain Depression/mental illness Heart disease High blood pressure Kidney disease Stroke Thyroid disease Other Page 4 of 8
5 MEDICATIONS Pharmacy Name and Location: Phone: Are you currently taking any PRESCRIPTION MEDICATIONS? If yes, list all prescription medications, over-the-counter medications, vitamins, and herbal supplements: MEDICATION DOSAGE TIMES PER DAY HAVE YOU HAD THIS PRESCRIPTION FILLED IN THE PAST 60 DAYS? Please list any other PAIN MEDICATIONS you have used in the PAST, including over-the-counter medications: MEDICATION DOSAGE TIMES PER DAY EFFECTIVENESS Are you currently taking BLOOD THINNERS (i.e., PLAVIX, Coumadin, Warfarin, Heparin, or Aspirin)? If yes, please list: ALLERGIES Please list all MEDICATIONS you are allergic or intolerant to and your reaction: MEDICATION REACTION Please list any other allergy or intolerance that might be pertinent (i.e., latex, Iodine, shellfish, or contrast dye): Page 5 of 8
6 SOCIAL HISTORY Personal and Marital Status. Do you live alone? Describe your home: Single level Multi-level Circle the word that best describes your current marital status: Married Single Divorced Widowed Domestic Partner If married, how is your marriage? Good Average Fair Poor How many children do you have? Do you take care of other family members? How many children are living with you? Education. What is the highest level of education you have finished? Employment. Are you currently working? If you are not working, has pain forced you to stop working? Previous / current occupation: Are you being treated under Workers Compensation? Are you currently receiving disability benefits? Habits. Circle the word that best describes your general stress level: Low Medium High Circle the word that best describes your exercise level: None Occasionally Moderately Heavily Are you involved in sporting activities? List activities: Circle the word that best describes your diet: Regular Vegetarian Vegan Gluten free Carbohydrate Specific carbohydrate Do you drink caffeinated drinks? How many drinks per day? Do you drink alcoholic beverages? How often? Occasionally Moderately Heavily Do you smoke? How often? Occasionally Moderately Heavily Number packs per day: Number of years smoking: Do you use recreational/street drugs? How often? Rarely Occasionally Often If yes, please list: PSYCHOSOCIAL HISTORY Circle the word that best describes how your pain makes you feel: Depressed Angry Frustrated Helpless/hopeless Loss of interest in hobbies/activities Have you ever been treated for depression? When? Have you ever been treated for emotional/behavioral disorders? Do you currently have ACTIVE suicidal thoughts? Do you have a history of alcohol abuse? Do you have a history of drug abuse? Do you have a history of suicidal attempts? Do family members have a history of alcohol abuse? Circle, if applicable: Marijuana Cocaine Amphetamines Do you have any immediate family members with a history of drug abuse? Page 6 of 8
7 SYSTEMS REVIEW Please circle below if you are experiencing or have recently experienced any of the following: Constitutional: Weight gain ( lbs) Weight loss ( lbs) Exercise intolerance Chills Fever Night sweats Eyes / Ears / Nose: Dry eyes Irritation Vision change Difficulty hearing Frequent nosebleeds Sinus pressure/drainage Mouth / Throat: Teeth abnormalities Bleeding gums Mouth ulcer Dry mouth Mouth breathing Snoring Oral abnormalities Sore throat Cardiovascular: Chest pain on exertion Arm pain on exertion Palpitations Known heart murmur Light-headed on standing Respiratory: Cough Coughing up blood Wheezing Shortness of breath, when walking Shortness of breath, when lying Sleep apnea Gastrointestinal: Change in appetite Abdominal pain Nausea/vomiting Vomiting blood Diarrhea Constipation Black/bloody stools Genitourinary: Difficulty urinating Increased urinary frequency Urinary loss of control Incomplete emptying Blood in urine Musculoskeletal: Muscle aches Muscle weakness Joint pain Back pain Swelling in the extremities Integumentary (skin / breast): Dry skin Itching Rash Jaundice Abnormal mole Growths/lesions Neurological: Frequent or severe headaches Migraines Numbness Weakness Dizziness Seizures Loss of consciousness Restless legs Psychiatric: Sleep disturbances Restless sleep Feeling unsafe in relationships Depression Confusion Alcohol abuse Endocrine: Fatigue Increased thirst Cold intolerance Hair loss Increased hair growth Hematologic / Lymphatic: Swollen glands Easy bruising Excessive bleeding Allergic / Immunologic: Runny nose Sinus pressure Itching Hives Frequent sneezing Page 7 of 8
8 PAIN S EFFECT ON ACTIVITIES OF DAILY LIVING Circle ONE number in each section that best describes how your pain has affected your everyday life: Section 1 Pain Intensity Section 6 Standing 1 I have no pain at the moment. 1 I can stand as long as I want without extra pain. 2 The pain is very mild at the moment. 2 I can stand as long as I want, but it causes extra pain. 3 The pain is moderate at the moment. 3 Pain prevents me from standing more than 1 hour. 4 The pain is fairly severe at the moment. 4 Pain prevents me from standing more than ½ hour. 5 The pain is very severe at the moment. 5 Pain prevents me from standing more than10 minutes. 6 The pain is the worst imaginable at the moment. 6 Pain prevents me from standing at all. Section 2 Personal Care Section 7 Sleeping 1 I can look after myself normally without extra pain. 1 My sleep is never disturbed by extra pain. 2 I can look after myself, but it is very painful. 2 My sleep is occasionally disturbed by extra pain. 3 It is painful to look after myself, and I am slow and careful. 3 Because of pain, I have less than 6 hours of sleep. 4 I need some help but can manage most of my personal care. 4 Because of pain, I have less than 4 hours of sleep. 5 I need help every day in most aspects of self-care. 5 Because of pain, I have less than 2 hours of sleep. 6 I do not get dressed, I wash with difficulty, and I stay in bed. 6 Pain prevents me from sleeping at all. Section 3 Lifting Section 8 Sex Life (if applicable) 1 I can lift heavy weights without pain. 1 My sex life is normal and without extra pain. 2 I can lift heavy weights, but it gives me extra pain. 2 My sex life is normal but causes some extra pain. 3 Pain prevents me from lifting heavy weights off the floor, but 3 My sex life is somewhat normal but is very painful. I can manage if they are conveniently positioned. 4 My sex life is severely restricted by pain. 4 Pain prevents me from lifting weights, but I can manage light 5 My sex life is absent because of pain. to medium weights if they are conveniently positioned. 6 Pain prevents any sex life at all. 5 I can lift only very light weights. 6 I cannot lift or carry anything at all. Section 9 Social Life 1 My social life is normal and is without pain. Section 4 Walking 2 My social life is normal but increases the degree of pain. 1 Pain does not prevent me from walking any distance. 3 Pain has no significant effect on my social life apart 2 Pain prevents me from walking more than 1 mile. from limiting my more energetic interests (e.g. sports). 3 Pain prevents me from walking more than ¼ mile. 4 Pain has restricted my social life, and I don t go out often. 4 Pain prevents me from walking more than 100 yards. 5 Pain has restricted my social life to my home. 5 I can walk only using a stick or crutches. 6 I have no social life because of pain. 6 I am in bed most of the time and have to crawl to the toilet. Section 10 Traveling Section 5 Sitting 1 I can travel anywhere without extra pain. 1 I can sit in any chair as long as I like. 2 I can travel anywhere, but it gives me extra pain. 2 I can sit in my favorite chair as long as I like. 3 Pain is bad, but I manage journeys over 2 hours. 3 Pain prevents me from sitting more than 1 hour. 4 Pain restricts me to journeys of less than 1 hour. 4 Pain prevents me from sitting more than ½ hour. 5 Pain restricts me to short journeys less than 30 minutes. 5 Pain prevents me from sitting more than 10 minutes. 6 Pain prevents me from traveling except to receive 6 Pain prevents me from sitting at all. treatment. TOTAL: In signing this document, I hereby acknowledge that the information that I have provided is true and accurate to the best of my knowledge. Falsification of this information may be grounds for discharge from this practice. I understand that this information will be used by the company s pain management specialists in developing a comprehensive treatment plan. Name of Patient: Date of Birth: Signature of Patient: Date: Name of Personal Representative (if applicable): Relationship: Signature of Personal Representative: Date: Page 8 of 8
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Cell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:
Practice: Today s Date: Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E-mail newsletters, reminders, statements, etc. Address: City: State:
HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
1 UT Health Austin Comprehensive Pain Management New Patient Questionnaire Thank you for scheduling a visit with the Comprehensive Pain Management Care Team. The responses you provide to these questions
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.
Questionnaire for Lipedema Patients
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Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
New Patient Information
(Please Print) New Patient Information Name Address City/State/Zip Cell: Home: email: Social Security # Birthdate Age Male Female Occupation Employed by Wk ph. # Address City/State/Zip Number of Children
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
SANTA MONICA BREAST CENTER INTAKE FORM
SANTA MONICA BREAST CENTER Who referred you to see us today? Who is your primary care physician? Are there any other MDs who you would like to receive today s visit information? No Yes MD contact info
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)
1275 Olentangy River Rd. Ste 120 Columbus, Ohio 43212 Telephone (614) 291-5555 Fax: (614) 291-7720 Dr. David B. Kaplansky Dr. Randall Contento PATIENT Dr. INFORMATION Garrett Kalmar FORM www.columbusohiopodiatrist.com
Laser Vein Center Thomas Wright MD Page 1 of 4
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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
SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE
Patient Name MRN DATE: SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE Date of birth Age REASON FOR VISIT Abnormal Mammogram R L please specify Lump/Thickening R L upper lower inner outer Pain R L upper
IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED
Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form
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PAIN INFORMATION SHEET
PAIN INFORMATION SHEET PLEASE MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE SENSATIONS DESCRIBED BELOW. PLEASE USE THE APPROPRIATE SYMBOL & INCLUDE ALL AREAS. **** ==== OOOO XXXX //// ACHE **** NUMBNESS
Name Date Date of Birth. Age Sex: M F Height: ft. in. Weight lbs. Primary Physician Referring Physician (If Different) When did the pain begin?
(Please fill out this form and bring it with you to your appointment.) Name of Birth Age Sex: M F Height: ft. in. Weight lbs Primary Physician Referring Physician (If Different) CURRENT PROBLEM Please
Initial Pain Management Patient Questionnaire
Appt. Date: Appt. Time: Boston Out-Patient Surgical Suites North Tel Fax: 781-407-5892 Initial Pain Management Patient Questionnaire Dear New Pain Management Patient, Welcome to the New England Pain Management
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?
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -SPINE Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status
Workers Compensation Intake Form File Number (Office Use) Patient Information: Today s Date Home Phone Name Cell Phone I prefer to be called Preferred Contact Home Cell Email Social Security No. Date of
WESTERN NEUROSURGICAL CLINIC MEDICAL EVALUATION QUESTIONNAIRE. Name: Date of Birth. Age: Social Security No.: Driver's Lic.# Occupation: Employer:
Date: IDENTIFICATION: WESTERN NEUROSURGICAL CLINIC MEDICAL EVALUATION QUESTIONNAIRE Name: Date of Birth Age: Social Security No.: Driver's Lic.# Occupation: Employer: ******************************************************************************
Name: DOB: Age: Phone: Phone: Is this an injury related to a : (circle one) Other? Yes / No (Please Explain)
Family/Primary Doctor: Emergency Contact: Name Phone: Phone: Who referred you to our office? Who else have you seen for this condition? INSTRUCTIONS: Please provide the following information, in detail.