Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?

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Transcription:

Gregory H. Tchejeyan, M.D., Inc. Please fill out this form in its entirety. Please complete every line item, as it is necessitated by regulations from the government (Health Care Finance Administration HCFA) Page: 1 Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: Height: Weight: I. What are you being seen for today? II. Which side is affected? O Right O Left O Bilateral III. Date of Injury or start of pain: How did the pain occur? O Injury O Chronic O Spontaneous Is this work related? O Yes O No Is this the result of a motor vehicle accident? O Yes O No IV. Pain Description Quality of your pain? O Mild O Moderate O Severe Type of pain? O Sharp O Dull O Other: Have you had physical therapy? O Yes O No Are you taking any pain medications? Anti-inflammatory agent O Yes O No Drug Name: Pain Medication O Yes O No Drug Name: Tylenol O Yes O No Have you been putting ice on the area? O Yes O No Have you had any testing? O MRI O EMG/NCS O Bone Scan O CAT Scan Are you? O Left handed O Right handed

Page: 2 Do you have or have you had: Medical History Asthma/ COPD O Yes O No Cancer O Yes O No Diabetes O Yes O No High Blood Pressure O Yes O No Acid Reflux Disease O Yes O No Heart Attack O Yes O No Osteoporosis O Yes O No Hypertension O Yes O No Emphysema O Yes O No Seizures O Yes O No Stroke O Yes O No Arthritis O Yes O No Gout O Yes O No Thyroid Disease O Yes O No Kidney Problems O Yes O No Blood Clots O Yes O No Social History Marital status: O Single O Married O Widowed O Divorced Do you smoke? O Yes O No O Previously If yes, How many packs/ day? O <1 O 1-2 O >2 How many years have you smoked? O 1-4 O 5-10 O >11 Do you consume alcohol? O Yes O No In the past did you consume alcohol? O Yes O No

Page: 3 How often do you consume alcohol? O Daily O Social O Never Do you exercise regularly? O Yes O No Working Status: O Full time O Part Time O Student O Unemployed Family History Father O Arthritis O Cancer O Diabetes O Stroke O Heart Trouble O Lung Disease Mother O Arthritis O Cancer O Diabetes O Stroke O Heart Trouble O Lung Disease Siblings O Arthritis O Cancer O Diabetes O Stroke O Heart Trouble O Lung Disease Grandparents O Arthritis O Cancer O Diabetes O Stroke O Heart Trouble O Lung Disease Review of Systems Are you experiencing any of these issues now? Constitutional: Fatigue O Yes O No Weight change O Yes O No Fever O Yes O No Neurological: Headache O Yes O No Numbness/ Tingling O Yes O No Seizures O Yes O No Dizziness O Yes O No Coordination Problems O Yes O No Neck Pain O Yes O No Respiratory: Shortness of Breath O Yes O No Chest Pain O Yes O No Trouble Breathing O Yes O No Wheezing/ Asthma O Yes O No Chronic Coughing O Yes O No

Page: 4 Coughing up Blood O Yes O No Cardiovascular: Chest Pain O Yes O No Irregular Heartbeat O Yes O No High Blood Pressure O Yes O No Leg/Ankle swelling O Yes O No Spine: Severe Back Pain O Yes O No Curvature of the Spine O Yes O No Back Problems O Yes O No Musculoskeletal: Joint pain O Yes O No Joint stiffness O Yes O No Joint swelling O Yes O No Back Pain O Yes O No Gastrointestinal: Nausea/ Vomiting O Yes O No Stomach Ulcer / Reflux O Yes O No Diarrhea O Yes O No Blood in stool O Yes O No Skin: Rashes/sores O Yes O No Skin Cancer O Yes O No Itching/ Burning O Yes O No Hematological: Anemia O Yes O No Easy Bruising O Yes O No Bleeding problem O Yes O No Women Only: Are you, or could you possibly be pregnant? O Yes O No

Page: 5 Medications (Please list name and dosage): Allergies (Please list): Surgeries (Please list name and year): Patient Signature Date

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