NEW PATIENT INFORMATION

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Transcription:

OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF COMPLAINT Reason for visit: Location of your pain: Head Shoulder Mid Back Leg Ankle/Foot Wrist/Hand Neck Headaches Low Back Knee Hips/Buttocks Arm HISTORY OF PRESENT ILLNESS Date of injury or symptom onset: Type of injury: Sport Injury Job Accident Car Accident (Were you the Driver or Passenger? Seatbelted? No Yes) Other (explain): Please describe how you injured yourself: Please describe your current symptoms:

Circle the number that corresponds to the severity of your pain on a scale of 0-10. "0" means no pain and "10" is the worst pain you can imagine. At its worst: 0 1 2 3 4 5 6 7 8 9 10 At its best: 0 1 2 3 4 5 6 7 8 9 10 Which of the following best describes the character of your pain: Timing: Quality: Continuous, steady, constant Throbbing Burning Superficial Rhythmic, periodic, intermittent Aching Tingling/numbness Deep Brief, momentary, transient Sharp Dull (Frequency: Duration: ) What makes your pain worse? What makes your pain better? How long/far can you: Sit Stand Walk Since your injury is your pain: Better Same Worse If your pain is changed, what percentage? 10 20 30 40 50 60 70 80 90 100% Have you had any loss of bowel or bladder control? No Yes PREVIOUS TREATMENT Have you had treatment since your injury? No Yes Have you been to the ER for this? No Yes Have you had any of the following tests or procedures performed: X-Rays? No Yes MRI? No Yes Epidurals? No Yes CT Scan? No Yes EMG? No Yes Other (please explain) Medical: Dr. Date of 1 st visit Last visit Diagnosis given Medications given Treatment provided Chiropractic: No Yes Dr. Date of 1 st visit Last visit Diagnosis given Frequency: Every Day Three times/week Two times/week Weekly Has it helped? No Yes Physical Therapy: No Yes Therapist Date of 1 st visit Last visit Has it helped? No Yes Home exercise program given? No Yes

CURRENT MEDICATIONS: NAME DOSAGE HOW OFTEN DO YOU TAKE THIS PER DAY MEDICATION ALLERGIES No Yes If yes, please list: Name Reaction Are you allergic or had any reaction to iodine, shellfish, IVP dye, or contrast media? No Yes PAST MEDICAL HISTORY Anxiety Heart Attack Polio Thyroid trouble Depression Hypertension Asthma Heart Murmur Stroke High Cholesterol Alcoholism Liver disease Cancer Lung Disease Parkinson's Rheumatic Fever Hepatitis Chronic pain Diabetes Ulcers/PUD Arthritis Claustrophobia Other Have you ever had similar symptoms/injury before? No Yes If yes, when: Please describe briefly: PAST SURGICAL HISTORY Have you had any surgeries? No Yes If yes, please list type of surgery and approximate date: 1. 2. 3. 4. 5. 6. FAMILY HISTORY Please check box for any medical condition that a blood relative has a history of: Anxiety Heart Attack Polio Thyroid trouble Depression Hypertension Asthma Heart Murmur Stroke High Cholesterol Alcoholism Liver disease Cancer Lung Disease Parkinson's Rheumatic Fever Hepatitis Chronic pain Diabetes Ulcers/PUD Arthritis Claustrophobia Psychiatric illness Other

SOCIAL HISTORY Marital Status: (Check one or more) Single Married Divorced Widowed "Living together" Separated Number of children: Ages: Do you smoke? No Yes How much? Previous Smoker? No Yes When stopped? Do you drink alcohol? No Yes How much? Coffee, tea, cola beverages (cups/glasses/cans per day) Do you use recreational drugs? No Yes What type/how often? Are you currently employed? No Yes If yes, type of job REVIEW OF SYSTEMS: Please mark those items which you currently experience: GENERAL Fever Weight gain Weight loss Fatigue Chills Weakness Night sweats DERMATOLOGIC Jaundice Itching/rash Lesions Easy bruising HEAD/HEARING & VISION Trauma Headaches Tenderness Dizziness Ringing in ears Blindness Blurred vision Changes/loss Discharge Rings around lights Double vision Light sensitivity Glasses PULMONARY Wheezing Shortness of breath Chronic cough Coughing up blood CARDIOVASCULAR Chest pain Leg swelling Shortness of breath with exertion Racing heart GASTROINTESTINAL Nausea Abdominal pain Bloody stool Constipation Diarrhea Vomiting Stool color changes Heartburn Incontinence of bowels GENITOURINARY Blood in urine Vaginal discharge Pregnancy Pain/burning on urination Incontinence Venereal disease Sexual problems Painful menstruation Menopause Urgency/frequency with urination Irregular menstruation MUSCULOSKELETAL Arthritis Joint swelling Trauma NEUROLOGICAL Loss of Sensation Seizures Numbness and Tingling PSYCHOLOGICAL Sadness Anxiety Depression Patient Signature: Date:

OrthoNeuro Authorizations and Fianacial Policy Section 1: Appointment of Personal Representative to Receive Protected Health Information You may rely upon your spouse, relatives or friends to be involved in your medical care. OrthoNeuro can disclose your Protected Health Information to these people if you appoint them as your personal representatives. To appoint an individual as your personal representative, complete this section: I hereby appoint the following individual as my personal representative: Name: Relationship to me: I hereby authorize OrthoNeuro to disclose the following Protected Health Information to my personal representative: All Protected Health Information OR One or more of these choices: Times of Appointments Test Results Prescriptions & Ancillary Equipment Copies of Medical Records Other I may revoke my appointment of a personal representative at any time in writing. I understand that revocation of my appointment will NOT affect any action OrthoNeuro took in reliance on my appointment before it received written notice of my revocation. Please initial: Section 2: Receipt of Notice of Privacy Practices I hereby acknowledge receiving a copy of OrthoNeuro s Notice of Privacy Practices that outlines my privacy rights and explains how OrthoNeuro is permitted to use and disclose my Protected Health Information. I should call OrthoNeuro s Privacy Officer at (614) 890-6555 if I have a question or concern about my privacy rights. Please initial: Section 3: Patient Information Race: Ethnicity: Date of Birth: Language: Social Security Number: Emergency Contact: Phone Number: Section 4: Financial Policy I have reviewed OrthoNeuro s Financial Policy and Authorizations (collectively, the Financial Policy ), hereby acknowledge my responsibilities set forth in the Financial Policy, and hereby make the authorizations set forth in the Financial Policy. Please initial: By signing below, I am acknowledging that I have read and understand the financial policy and authorizations of OrthoNeuro Patient Name (please print) Patient Signature Date If applicable, Parent/Guardian Name If applicable, Parent/Guardian Signature Date (Please Print)

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