Patient Information Today s Date: Patient s Name: DOB: Age: Gender: Marital Status: M S D What would you like us to call you? Address: City, State, Zip: Home Phone: Cell Phone: Work Phone: Email: Preferred contact method: Is it ok to leave a voicemail message? On which number(s)? Emergency Contact: Emergency Contact Phone: Emergency Contact relationship to patient: Referring/Primary Care Physician s Name: Physician s Clinic and Phone: Preferred Pharmacy and Location: Pharmacy Phone Number: How did you hear about Wisconsin Integrative Pain Specialists? Who completed these forms? Other Notes: Chief Complaint/History What is the major reason for your visit today? What other health concerns/symptoms would you like addressed, when did they start and what have you done that has reduced the symptoms/helped you feel better? Are you currently under the care of a healthcare professional for a medical/health condition? Y N If yes, please describe condition(s) and list the healthcare professional you are seeing/have seen: Page 1 of 7
(cont.) Past Medical History What medical problems have you been treated for in the past? Eye disease Respiratory infection Ear infection Sinus problems Hay fever/allergic rhinitis Pneumonia Asthma Bronchitis Heartburn Anemia Migraine/headache Hypertension Arthritis/joint pain Dysautonomia/POTS Ehlers-Danlos Syndromes Thyroid disorder Blood clots Bleeding disorder Kidney problems Cancer Diabetes Eczema Infection Mast cell activation disorder Liver disease HIV/AIDS Other: Please list all prescription medications you currently take and how often YOU ACTUALLY TAKE them. Please bring ALL MEDICATIONS with you to your appointment in THE ORIGINAL CONTAINER. Name of Medication Dose (mg, ml, IU, etc.) Frequency Date Started Reason Patient s Name DOB Page 2 of 7
Please list all VITAMINS, MINERALS, HERBS OR OTHER SUPPLEMENTS you currently take and how often YOU ACTUALLY TAKE them. Name of Medication Dose (mg, ml, IU, etc.) Frequency Date Started Patient s Name DOB Page 3 of 7
Please list any Medication and/or Environmental/Food Allergies you may have. Allergen Reaction/Severity Social History What is your occupation? Do you work (circle all that apply) FULL TIME PART TIME OCCASSIONALLY Have you ever applied for or received disability benefits? Yes No Explain: What are your hobbies? Do you smoke/use tobacco of any kind? (Circle the appropriate answer) NEVER FORMER CURRENT If you have ever used tobacco, how much, when and how often? Do you use alcohol (currently or in the past)? If so, how much and how often? Have you ever used marijuana? If so, how much, when and how often? Patient s Name DOB Page 4 of 7
Have you ever used a drug differently than how it was prescribed? If so, please describe the circumstances (why, what, how often) Have you ever taken an illegal substance? If so, what, how much, when and how often? Family History Do you have family members who have been treated for the following conditions? Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Aunt Uncle Other Allergies Sinus Problems Pneumonia Asthma Bronchitis Heartburn Nasal Polyps Migraines/Headaches Hypertension Heart disease Arthritis Joint Pain Thyroid Disorder Cancer Diabetes Eczema Skin Infections Autoimmune Disorders Other? Patient s Name DOB Page 5 of 7
Review of Symptoms Please check any symptoms that you have experienced within the past three months: General Fever Chills Loss of appetite Increased appetite Unintentional weight loss of more than 10 pounds Weight gain of more than 10 pounds Night Sweats Fatigue Eyes Itching Excessive tears Dry eyes Pain Loss of vision Ears/Nose/Throat Congestion Sinus problems Coarse voice Dry nose/nosebleeds Ear pain Recurrent infections Sore throat Runny nose Ringing in ears/loss of hearing Heart Chest pain Irregular or skipped heartbeats Fast heartbeat/palpitations Respiratory Cough Wheeze Shortness of breath Difficulty taking in a deep breath Urinary Tract Difficulty urinating Painful urinating Recurrent urinary tract infections Skin Rash Eczema Swelling Hives/welts Hair loss Gastrointestinal Bloating Diarrhea Constipation Nausea Endocrine Sensitive to cold Sensitive to heat Feel the need to drink lots of water Abnormal periods/menstrual cycle Neurology Headaches Weakness Seizures Dizziness Mood Sleeping poorly Feeling fearful Persistent sadness Musculoskeletal Joint pain Joint swelling Muscle pain Tender points Patient s Name DOB Page 6 of 7
Evaluation for Joint Hypermobility (please circle the appropriate answer) Can you now, or could you ever, place your hands flat on the floor without bending your knees? Yes No Can you now, or could you ever, bend your thumb to touch your forearm? Yes No As a child, did you amuse family or friends by bending your body into strange shapes? Yes No As a child could you do a split? Yes No Have you had your shoulder, kneecap or hip dislocate (slip out and pop back in the place) on more than one occasion? Yes No Do you consider yourself double-jointed? Yes No What are your goals for this appointment? Is there anything else you would like us to know? Patient s Name DOB Page 7 of 7