Chad J Anderson D.C.

Similar documents
Patient Name: Cell Phone Home Phone Work Phone. Address City State Zip Address

NEW PATIENT QUESTIONNAIRE Spine pt acct #

Past Surgical History

Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Do you want statements ed? Y/N

Spine New Patient Questionnaire Rev

Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!

1607 Visa Dr, Ste 1A 408 E College Ave, Ste C Normal, IL Normal, IL 61761

New Patient Application

Saleeby Chiropractic Centre, P.A.

Dr. Pamela Milosevich The Healing Centre ~ 5 Allen Row ~ Montpelier, VT

Patient Name: Date: Address City State Zip Code. H. Phone W. Phone Cell Phone

Do not write in this box. Name: Appointment: Date: Appointment Time: Primary Care Provider: Phone: Fax: Referring Physician: Address:

ADVANCED SPINE HEALTH AND WELLNESS CENTER DR. PAUL BACON

Corner on Wellness Chiropractic Center Therapeutic Massage

Consent to Treat a Minor

New Patient Information

NAME: DATE: SPINE CENTER NEW PATIENT QUESTIONNAIRE

Healing Hands Chiropractic, LLC

BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage

WELCOME to the Florence Chiropractic and Wellness Center.

NEW PATIENT INFORMATION FORM

Patient Name: Date: Address City State Zip Code. H. Phone W. Phone Cell Phone. Primary Care Physician. Occupation. Employer

Back and Neck Pain Questionnaire

Name: DOB: Age: Phone: Phone: Is this an injury related to a : (circle one) Other? Yes / No (Please Explain)

Name: DOB: Today s Date:

HEALTH QUESTIONNAIRE

Worker s Compensation Form

Re-Exam Questionnaire

Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit)

Triple Crown Chiropractic Center Dr. Erik Simms D.C Clay Drive Walton, KY (859)

NEW PATIENT FORMS PLEASE FILL OUT AS COMPLETELY AS POSSIBLE

New Patient History Inventory

Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team

PERSONAL INJURY PATIENT HISTORY FORM

NAME OF PATIENT: STREET ADDRESS: CITY: STATE: ZIP: SEX: Male Female AGE: BIRTHDATE: MARITAL STATUS: PATIENT EMPLOYED BY: BUSINESS ADDRESS:

Patient Re-Examination Form

Welcome to Medina Family Chiropractic and Acupuncture!

Morris Medical Center, P.A.

PATIENT PERSONAL / CONFIDENTAL DATA

Pain Intensity (mark only 1) Personal Care (washing, dressing, etc.) Lifting (mark only 1) Walking (mark only 1) Sitting (mark only 1)

Initial Patient Health Assessment Form

MOTOR VEHICLE ACCIDENT PAIN CHART

Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #

The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C

3904 Meadowdale Blvd (o) N Chesterfield, VA (f)

R Number. Patient Intake

IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED

CERVICAL Orthopedic Specialists of Louisiana Pierce D. Nunley, MD PERSONAL INFORMATION. Patient Name:

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Address: Cell Phone Carrier. Social Security# - - Occupation Employer

Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)

CHRISTIANA SPINE CENTER NEW PATIENT QUESTIONNAIRE

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

Today s Date: Date of Birth: Age: Height: Weight: Who Referred: If not referred, how did you choose this office? Why are you seeing the doctor today?

PERSONAL INJURY QUESTIONNAIRE

* CC* PATIENT QUESTIONNAIRE

Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.

Chiropractic Case History/Patient Information. Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone:

Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone

Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:

Name: Date: Street Address: Referring Physician: How long have you had your current problem?

New Patient Intake Form

Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:

Chiropractic Case History/Patient Information

BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.

Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)

FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE

LUMBAR Orthopedic Specialists of Louisiana Pierce D. Nunley, MD PERSONAL INFORMATION. Patient Name:

DEPARTMENT OF NEUROSURGERY Spine Center New Patient Intake Form

New Patient Pain Evaluation

PATIENT NAME DATE CONSULTATION QUESTIONNAIRE

Pain Interventions 30 Hagen Drive, Suite Culver Rd. Suite 2 Rochester, NY Rochester, NY (Voice) (Fax)

2. Previous interventions, treatments, medications, surgery, or care you ve sought for your complaint(s):

PERSONAL HISTORY AUTO ACCIDENT QUESTIONNAIRE. Personal Injury Questionnaire. Name Date. Date of Accident: Time. Location of Accident (Streets)

HPM. Huntsville Pain Management Specialists in Interventional Pain Management James D. Thacker, M.D. NEW PATIENT MEDICAL INFORMATION

Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio

New Patient Form Welcome!

COOK CHIROPRACTIC CLINIC 1715 S MAIN ST KANNAPOLIS NC FX:

*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months

Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /

OhioHealth Orthopedic & Sports Medicine Physicians

PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: Internet: Fax:

New Patient Intake Form. Please List All Current Medications. Please shade in the areas where you have pain

Patient Data Sheet. Emergency Contact Name: Relationship: Contact phone number: Name: Specialty: Office address: Office phone: Fax:

History of Present Condition

PERSONAL INJURY QUESTIONNAIRE

CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:

Brisbin Family Chiropractic

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

\ NSMI. The National Sports Medicine InstJtute

SPINE AND ORTHOPEDIC PAIN CENTER, P.C. WINIFRED D. BRAGG, M.D.

Pain Clinic Packet Neal E. Coleman, MD Andrew Trobridge, MD Angelia Huffmeyer, FNP J. Mark Hannaford, PA Matthew Stinson, PA-C

Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)

Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy

Robert J. Brownsberger, M.D., PC New Patient Paperwork

Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician

Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:

Transcription:

Chad J Anderson D.C. New Patient Health History Form NAME: DATE: / / DOB: / / AGE: MARITAL STATUS: M / S / D / W ADDRESS: CITY: STATE: ZIP: PHONE: CELL PHONE: EMAIL: EMERGENCY CONTACT: PHONE#: RELATIONSHIP: REFERRED BY: OCCUPATION (IF RETIRED, FORMER OCCUPATION): EMPLOYER: CURRENT MD: PAST CHIROPRACTIC CARE? Y / N DR S NAME: Please answer the following questions on this page if you have a current open Worker s Comp or Personal Injury Case. (IF YOU DO NOT HAVE AN OPEN CASE PLEASE GO TO PAGE 2) Date of onset: Body part injured: Who is the worker s compensation carrier?

What is the reason you are seeking Chiropractic care today? Primary Condition? Secondary Condition? Third Condition? What caused the symptom(s)? Date the symptom(s) began? Instructions: Please circle the word or number that best answers the question being asked. Did the symptom(s) start: Suddenly? Gradually? Over how long of period? Is the symptom(s) getting: Better? Worse? Same? What percentage (%) of the day is your symptom(s) present? 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100 Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst. Example: HEADACHE NECK LOW BACK NO PAIN WORST POSSIBLE PAIN 1. What is your pain level right now? No Pain Worst Possible Pain 2. What is your typical average pain level (in a 24 hour period)? No Pain Worst Possible Pain 3. What is your pain level at its least (how close to zero 0 does the pain level get)? No Pain Worst Possible Pain 4. What is your pain level at its worst (how close to ten 10 does the pain level get)? No Pain Worst Possible Pain

On the Body Drawing below, mark where your pain is at describing the pain with the following letters: A= Achy Pain B= Burning Pain D= Dull Pain N= Numbing Pain S= Sharp Pain T= Traveling/Radiating Pain Is/Are your symptom(s) worse at a certain time of day? Y / N Morning, Noon, Afternoon, Evening, Night-Time Have you had this symptom before? Y / N (If No, go to page 4) If Yes; When was it before? (Approx. Date, or Year) Did you seek care? Y / N who did you see? What was the outcome? (Please Circle): Resolved, Better, No Change, Worse, Needed Surgery, Other If other; what was the outcome?

WHAT MAKES THE SYMPTOM(S) WORSE? (PLEASE CHECK ALL THAT APPLY) Motion of the HEAD Head Down Turning Left Tilting Left Head Up Turning Right Tilting Right Motion of the Low Back Bending Forward Twisting Left Side Bend Left Bending Backwards Twisting Right Side Bend Right ACTIVITIES: (THAT YOU CANNOT DO OR IS PAINFUL TO DO) Standing Dressing Driving Sitting House Work General Working Getting out of a Chair Yard Work Reading Sit to Stand Bending TV / Computer Putting on Socks Lifting Walking Sleeping Grooming Other If other, please describe: What makes the symptom(s) Better? (Less) Nothing Walking Prescription Meds Ice Sitting OTC Pain Meds Heat Laying Down Topical Gels Resting Stretching Other If Other, please describe: Please describe the quality of the symptom(s). Check all that apply! Dull Achy Pin-Needle Burning Spasm Sharp Throbbing Numbing Shooting Pressure

Past Medical History (Illness, Fractures Past and Current) 1. 2. 3. 4. 5. Past Surgical History 1. 2. 3. 4. 5. Allergies 1. 2. 3. Medications (Please List) Name of Medication Reason Prescribed 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Social History: Smoker Y / N Past Smoker Y / N Year Quit Tobacco Y / N Alcohol Y / N Children Exercise Days/Week Type Hobbies Family Health History (Only Health History of your Parents, Grandparents, and Siblings Needed) Cancer Heart Disease RA Strokes Migraines MS Parkinson s _ Women Only Are you currently Pregnant Y / N Date of last menstrual cycle If YES, Due Date # of Pregnancies Pregnancy outcomes: Natural birth C-Section Still Born Aborted Breast Augmentation Surgery Y / N Pelvic Inflammatory Disease Y / N Endometriosis Y / N Fibroids Y / N

Low Back Disability Questionaire (Revised OSWESTRY) Instructions: This questionnaire has been designed to enable us to understand how your back pain has affected your ability to manage your everyday activities. Please answer each section by marking the ONE CHOICE that most applies to you. We realize you may feel that more than one statement may relate to you. PLEASE JUST MARK THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YUR PROBLEM RIGHT NOW Section 1 Pain Intensity o I can tolerate the pain without having to use painkillers o The pain is bad, but I can manage without having to take painkillers o Painkillers give me complete relief from pain o Painkillers give me moderate relief from pain o Painkillers give very little relief from pain o Painkillers have no effect on the pain and I do not use them Section 2 Personal Care (Washing, Dressing, etc) o I can look after myself normally without causing extra pain o I can look after myself normally but it causes extra pain o It is painful to look after myself and I am slow and careful o I need some help but manage most of my personal care o I need help every day in most aspects of self-care o I do not get dressed, I wash with difficulty and stay in bed Section 3 Lifting o I can lift Heavy weights without extra pain o I can lift heavy weights but it causes extra pain o Pain prevents me from lifting weights off the floor, but I can manage if they are conveniently positioned, ie on a table o Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. o I can lift very light weights o I cannot lift anything at all Section 4 Walking o Pain does not prevent me from walking any distance o Pain prevents me from walking more than one mile o Pain prevents me from walking more than one-half mile o Pain prevents me from walking more than one-quarter mile o I can only walk using a stick, cane, or crutches o I am in bed most of the time and have to crawl to the toilet Section 5 Sitting o I can sit in any chair as long as I like o I can only sit in my favorite chair for as long as I like o Pain prevents me from sitting more than one hour o Pain prevents me from sitting for more than 30 minutes o Pain prevents me from sitting for more than 10 minutes o Pain prevents me from sitting all of the time Section 6 Standing o I can stand as long as I want without extra pain o I can stand as long as I want but it causes extra pain o Pain prevents me from standing more than 1 hour o Pain prevents me from standing more than 30 minutes o Pain prevents me from standing more than 10 minutes o Pain prevents me from standing at all Section 7 Sleeping o Pain does not prevent me from sleeping well o I can sleep well only by taking medication o Even when I take medication I sleep less than 6 hours o Even when I take medication I sleep less than 4 hours o Even when I take medication I sleep less than 2 hours o Pain prevents me from sleeping at all Section 8 Social Life o My social life is normal and gives me no extra pain o My social life is normal but it increases the degree of pain o Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing o Pain has restricted my social life and I do not go out as often o Pain has restricted my social life to my home o I have no social life because of my pain Section 9 Traveling o I can travel anywhere without extra pain o I can travel anywhere but it causes extra pain o Pain is bad but I manage journeys over 2 hours o Pain is bad but I manage journeys less than 1 hour o Pain restricts me to short necessary journeys under 30 minutes o Pain prevents me from traveling except to the doctor or hospital Section 10 Changing Degree of Pain o My pain is rapidly getting better o My pain fluctuates but overall is definitely getting better o My pain seems to be getting better but the improvement is slow at best o My pain is neither getting better nor worse o My pain is gradually getting worse o My pain is rapidly getting worse

Review of Systems: Have you had any of the following health issues? (write C for current, P for past) 1. Pulmonary Asthma COPD Emphysema 2. Endocrine Hormonal Replacement Diabetes Steroid Shots Thyroid Disease Adrenal Insulin Pump 3. Dermatomal (skin) Significant Burns Significant Rashes Skin Grafts Psoriasis Melanomas Skin Cancer Plastic Surgery 4. Neurological (Nerve) Vision Loss Lost Strength Lost Feeling Seizures Headaches Memory Loss Tremors Tremors Lost Smell Lost Taste Dizziness Vertigo 5. Hematological (Blood) Anemia Anti-Inflammatory use (OTC, Aleve, Aspirin) HIV/AIDS Bleeding/Bruising Sickle-Cell Anemia Large Lymph Nodes Hemophilia Blood Clots Phlebitis 6. Cardiovascular (Heart) Heart Attack Heart Surgery Stroke Congestive Heart Failure TIA s Angina Irregular Heart Beat High Blood Pressure High Cholesterol Heart Murmer Mitral Valve Replacement 7. Renal (Kidney) Kidney Stones Blood in Urine Bladder Control Bladder Infections Dialysis Hard to Urinate Kidney Disease 8. Gastroenterological (Digestion) Nausea Hard to Swallow Ulcerative Colitis Abdominal Pain Hiatal Hernia Constipation Gall Stones Pancreatic Disease IBS Heart Burn Bowel Incontinences 9. Musculo-Skeletal (Muscle and Bone) Rheumatoid Arthritis Gout Osteoarthritis Osteopenia Osteoporosis Bone Fractures Spinal Fractures Spinal Surgery Scoliosis Metal Implants

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback