New Patient Intake Form

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Transcription:

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 Home Phone ( _) - Work Phone ( ) - Cell Phone ( ) - Email Date of Birth / / Sex: Male Female Marital Status: Single Married Other How did you hear about our office? Medical Conditions: (Check all that apply to you) Arthritis Cancer Diabetes Heart Disease Hypertension Psychiatric Illness Skin Disorder Stroke Other _ Fibromyalgia Asthma Osteoporosis Surgeries: (Check all that apply to you) Appendectomy Cardiovascular procedure Cervical spine Hysterectomy Joint Replacement Prostate Lumbar spine Gall Bladder Brain Shoulder Thoracic spine Knee Carpal Tunnel Gastro-intestinal Uro-genital Hernia Breast Augmentation Other _ Allergies: (Check all that apply to you) Mold Seasonal Milk or Lactose Animal Chemical Sulfites Wheat/Glutens Other 1

Social History: (Check all that apply to you) Caffeine use: occasional often never Drink Alcohol: occasional often never Exercise: occasional often never Drink Water: <64 oz/day >64 oz/day never Cigarettes: <1 pack/day >1 pack/day never Sleep: <8 hours/night >=8 hours/night Insomnia Other _ Family History: (Check all that apply) Arthritis: Parent Sibling Cancer: Parent Sibling Diabetes: Parent Sibling Heart Disease Parent Sibling Hypertension Parent Sibling Stroke Parent Sibling Thyroid Parent Sibling Other Occupational Activities: (Check one that best describes your job) Administration Business Owner Clerical/Secretary Computer User Heavy Equipment operator Daycare/Childcare Construction Health Care Food Service Industry Medium Manual Labor Manufacturing Home Services Heavy Manual Labor Light Manual Labor Executive/Legal Housekeeper Other 2

Review of Systems (Check box if you have had trouble with any of the following) Cardiovascular Respiratory Allergic/Immunologic Past Present No Past Present No Past Present No Poor Circulation Asthma Hives Hypertension Tuberculosis Immune Disorder Aortic Aneurism Short Breath HIV/AIDS Heart Disease Emphysema Allergy Shots Heart Attack Cold/Flu Cortisone Use Chest Pain Cough High Cholesterol Wheezing Pace Maker Ear, Nose and Throat Jaw Pain Eyes Past Present No Irregular Heartbeat Past Present No Difficulty Swallowing Swelling of legs Glaucoma Dizziness Double Vision Hearing Loss Genitourinary Blurred Vision Sore Throat Past Present No Nosebleeds Kidney Disease Psychiatric Bleeding Gums Burning Urination Past Present No Sinus Infections Frequent Urination Depression Blood in Urine Anxiety Gastrointestinal Kidney Stones Stress Past Present No Lower Side Pain Gall Bladder Problems Endocrine Bowel Problems Neurologic Past Present No Constipation Past Present No Thyroid Liver Problems Stroke Diabetes Ulcers Seizures Hair Loss Diarrhea Head Injury Menopausal Nausea/Vomiting Brain Aneurysm PMS Bloody Stools Numbness Poor Appetite Severe Headaches Hematologic Pinched Nerves Past Present No Musculoskeletal Parkinson s Hepatitis Past Present No Carpal Tunnel Blood Clots Gout Vertigo Cancer Arthritis Bruising Joint Stiffness Constitutional Bleeding Muscle Weakness Past Present No Fever, Chills Osteoporosis Sweating Broken Bones Weight Loss/Gain Varicose Vein Joints Replaced Low Energy Level Difficulty Sleeping Please list all current medications being taken Neck Pain Low Back Pain Upper Back Pain How are your symptoms changing? Getting better Not changing Getting worse Are You Pregnant? (Circle) Yes No 3

By Using the key below, indicate on the body diagram where you are experiencing the following symptoms: N=Numbness B=Burning S=Sharp T=Tingling A=Dull Ache Average Pain Intensity: Last 24 hours: no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain Past week: no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain Does anything improve your pain? Yes No If Yes, please list: When did your symptoms begin? Are your symptoms a result of: Motor Vehicle Accident Work related Accident Other How did your symptoms begin? How often do you experience your symptoms? Constantly Frequently Occasionally Intermittently (76-100% of the day) (51-75% of the day) (26-50% of the day) (0-25% of the day) What describes the nature of your symptoms? Sharp Ache Numb Shooting Burning Tingling Throbbing Other 4

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