Samuel A. Joseph, Jr., M.D. In order to be seen by one of our physicians, you must bring the following to your visit:

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Samuel A. Joseph, Jr., M.D. Your appointment has been scheduled: Your appointment time is: Please arrive at: o o o 2727 West Dr. Martin Luther King Jr. Blvd. Suite 590 Tampa, FL 33607 1840 Mease Drive (Medical Arts Building) Suite 309 Safety Harbor, FL 34695 710 94 th Avenue North Suite 309 St. Petersburg, FL 33702 In order to be seen by one of our physicians, you must bring the following to your visit: New Patient Packet completed MRI films, CT films, X-Ray films and reports for all films. Photo ID Insurance ID If you have any questions related to your MRI films, CT, X-Ray, or reports, please call (813) 534-6269. Thank you, Joseph Spine, PA

NEW PATIENT INFORMATION Chart: Date: Patient Name: DOB: Age: Primary Care Physician: Male / Female (circle one) ( ) Right Handed ( ) Left Handed Is your problem related to: Auto Accident: [ ] Yes [ ] No Date: Job Injury: [ ] Yes [ ] No Date: Other: [ ] Yes [ ] No Date: Which physician can we thank for your referral? Briefly describe your main complaint/problem. Also, describe the injury that caused these symptoms, if applicable: How long have you had this problem? [For physician use only. History of present illness. (Preliminary notes: refer to dictation for more details]

Using the symbols below, please draw in the location of your symptoms on the diagrams. X = Pain 0 = Numbness / = Aching * = Pins & Needles If you have NECK PAIN, what percentage of your pain is % Neck and % Arm (Total 100%) If you have BACK PAIN, what percentage of your pain is % Back and % Leg (Total 100%) Mark an X on the line indicating the usual degree of the pain : (0 = no pain and 10 = the worst pain) 0 1 2 3 4 5 6 7 8 9 10 Least Pain Worst Pain

What position/activity makes the pain worse/better? Bending Bowel Movement Coughing General Activity Home Remedies Lying Down Sitting Standing Walking Better Worse Comments Please check which TREATMENTS you have had for your main problem/complaint and indicate whether they were helpful. Treatment Helpful? Treatment Helpful? Treatment Helpful? Electric Massage Whirlpool Stimulation T.E.N.S. Pool Injections Exercises Ultrasound Home Acupuncture Exercises Hot Packs Manipulation Cold Other: Botox How long can you STAND with no or minimal pain? minutes. WALKING DISTANCE with no or minimal pain: [ ] 0-50 ft [ ] 50-200 ft [ ] 200-500 ft [ ] 500+ ft [ ] ½ mile + Do you need SUPPORT to help you walk? [ ] Y [ ] N If yes, what kind of brace? 710 94th Avenue, Suite 309 St Petersburg, Florida 33702 Phone: 727-202-5093

List below the PREVIOUS PHYSICIANS (MD, DO, Chiropractor) you have seen for your main complaint/problem. Physician Specialty Dates Treatment Indicate which DIAGNOSTIC STUDIES you have had in evaluation of your main complaint/problem. (include dates) Test Date Test Date Test Date X- Ray EMG/NVC/SSEP CT Scan Bone Scan Arthogram Dexa Scan Myelogram MRI Diskogram Other: PAST MEDICAL HISTORY Check below if you have had any of the following: Bowel disorders Cancer-where Depression Diabetes Heart disease High blood pressure High cholesterol Kidney disease Lung disease Multiple myeloma Comments Comments Osteoporosis Pacemaker Polio Psoriasis Rheumatoid arthritis Seizures Serious infection Stroke Thyroid condition Ulcers Other:

List any SURGERY OR SURGERIES you have had: Type Date Outcome List any DRUG ALLERGIES you have: Drug Type of Reaction List ALL CURRENT MEDICATIONS as follows: Name Dose (Milligrams, grams) How Often (per day) How Long

SOCIAL HISTORY & HABITS Occupation: Marital Status: Single Married Separated Divorced Widowed Highest Level of Education: Less than high school High school graduate Some college Postgraduate Unknown WORK STATUS [ ] Full duty [ ] Light duty [ ] Off duty per physician [ ] Unemployed [ ] Retired If you are NOT working a full day, how long have you been off work? Have you had a work capacity assessment? [ ] Yes [ ] No Are you disabled through Social Security? [ ] Yes [ ] No TOBACCO USE Do you currently use tobacco products? [ ] Yes [ ] No Start Age/Year: Stopped If yes, indicate quantity per day: Cigarettes Cigars Chewing Tobacco (snuff) ALCOHOL USE Do you currently consume alcoholic beverages? [ ] Yes [ ] No If yes, indicate quantity per day: Beer Wine Distilled Spirits

FAMILY HISTORY Has any member of your family been diagnosed with any of the following conditions (include deceased family members)? Place an X under the correct family member with the condition, and indicate if the family member passed away due to that condition. Father Mother Father s Mother s Brother(s) Sister(s) Parents Parents Anemia Arthritis Bleeding Disorder Cancer Coronary Artery Disease Diabetes Mellitus Gout Hypertension Osteoporosis Seizures Sickle Cell Disorder Other: VITALS: Weight: Height: (Females only) LMP: (Recorded by nurse) Blood Pressure: /

REVIEW OF SYSTEMS: Please place a check mark in the box next to any of the following symptoms or problems if you have experienced them recently or have concerns about them. If you don t understand something place a question mark? by it. Your doctor will discuss any positive responses with you. General: Weight Gain Last 6 Months Weight Loss Last 6 Months Poor Appete Night Sweats Chills Fever Skin: Rash HEENT: Recent Changes in Vision Recent Changes in Hearing Recent Changes in Smell Recent Changes in Taste Respiratory: Short of Breath Cough Sputum History of Tuberculosis Wheezing Cardiovascular: Chest Pain Palpitaons Shortness of Breath with Exercise Murmur Feet Edema Musculoskeletal: Cramps Muscle Weakness Joint Pain Joint Swelling Morning Sffness Gastrointesnal: Nausea Voming Diarrhea Indigeson Abdominal Pain Bloody or Dark Stools Unable to Control Bowel Neurological: Numbness/Tingling Feet Numbness/Tingling Hands Convulsions Dizziness Genitourinary: Blood in Urine Urinary Tract Infecons Unable to Control Bladder Rushing to go Need to go Frequently Psychiatric: Problem Sleeping Crying Spells Hematology: Easy Bleeding Easy Bruising The preceding patient information packet has been reviewed and discussed with my patient. PHYSICIAN SIGNATURE Date:

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