New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:

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Transcription:

New Patient Packet Patient Name: DOB: Age: Sex: Male / Female Height: Weight: PHYSICIAN CARE Primary Care Physician: Address: City: State: Zip: Phone: Fax: Referring Physician (if different from PCP): Specialty: Address: City: State: Zip: Phone: Fax: PHARMACIES Primary Pharmacy Type: Local Mail-Order Specialty Name: Address: City: State: Zip: Phone: Fax: PATIENT HISTORY Reason for visit Chief Complaint (History of Present Illness) Please describe the major problem that brings you in today to see a Neurologist:

Past Medical History Have you ever been diagnosed with any of the following medical conditions? Please list any other conditions not listed in the space below. YES NO Condition MONTH/YEAR Anemia Asthma Arthritis, which joints mostly? Atrial Fibrillation Bipolar Disorder Cancer, What type (s): Cataracts Cerebral Palsy Chronic Obstructive Pulmonary Disease (COPD) Chronic Kidney Disease Coronary Artery (Heart) Disease Congestive Heart Failure Chronic Liver Failure Concussion Depression Diabetes Epilepsy / Seizures Fibromyalgia Glaucoma Gastric Ulcers Headaches / Migraines High Blood Pressure High Cholesterol HIV Lupus Memory Difficulties Miscarriages Multiple Sclerosis Myasthenia Gravis Parkinson Disease Stroke (Cerebrovascular Accident) Spinal Cord Injury Traumatic Brain Injury Other (please specify):

Surgical History Have you had any of the following surgical procedures? Please list any other surgeries not listed in the space below. YES NO SURGERY TYPE DATE/MONTH/YEAR Appendectomy Brain Surgery Breast Surgery CABG (open heart surgery) Colon Surgery Cosmetic Surgery C-Section Eye Surgery Fracture (bone) Surgery Hernia Repair Hysterectomy Joint Replacement (knee, hip, etc.) Small Intestine Surgery Spine Surgery Tubal Ligation Vasectomy Valve Replacement Other (please specify): Allergies Please list your Allergies and Reactions to any Foods, Drugs, Radiology Dyes, and Allergy Triggers resulting from a Chronic Condition. (Ex. Allergic to: Eggs, Penicillin, Sulfas, Iodine, Local Anesthetics (Lidocaine), Latex, Contrast, Perfume, Smoke ) (Ex. Reactions: Hives, Shortness of Breath, Trouble Breathing/Wheezing, and Anaphylaxis ) Females: Are you, or could you be pregnant? (Circle one) Yes / No Last menstrual period Ever use Oral Contraceptives? Ever used Hormone Replacement Therapy?

CURRENT MEDICATION LOG List any medication or over the counter/herbal supplements you are currently taking: Medication Start Date Dose/Frequency Prescribing Physician Comments Please List any over the counter medications, supplements, herbal treatments, or alternative medications that you may be taking:

Social History: Occupation: Marital Status: Number of children: Hobbies: Do you smoke cigarettes? If so, how many packs a day? At what age did you start? If applicable, at what age did you stop? Do you drink alcohol? If yes, how much daily? At what age did you start? If applicable, at what age did you stop? Do you use recreational drugs? Type? Do you exercise regularly? (Circle one) No Yes How frequently? Family History: Does anyone in your family have any of the following Medical Conditions, please indicate who. Memory Difficulty: NO YES Family Member: Seizures: NO YES Family Member: Stroke: NO YES Family Member: Parkinson s disease: NO YES Family Member: Multiple Sclerosis: NO YES Family Member: Cancers: NO YES Family Member: Type of Cancer: Diabetes NO YES Family Member: Heart Disease NO YES Family Member / what age: Others: Family Member: Medical Condition:

Review of Symptoms/Chronic Conditions Do you currently, or have you had a problem with: Constitutional: Fever Unexplained weight loss >10 lbs. Excessive fatigue History of Falls Eyes: Wear glasses Infections Injuries Ear, Nose, Throat& Mouth: Wear hearing aid(s) Hearing loss Ear pain/infections Ringing in ears Nose bleeds Nasal congestion/drainage Inability to smell Sinus problems Balance (vertigo, spinning, etc.) Cardiovascular: Chest pain or angina High blood pressure Irregular pulse / Palpitations Heart murmur Swelling in hands or feet Leg pain while walking Respiratory: Shortness of breath Bloody sputum Gastrointestinal: Nausea Vomiting Blood in your vomit Abdominal pain Change in bowel habits Chronic Pain: Back Pain Neck Pain Headache Limb Pain Abdominal Pain Chest Pain Circle One Endocrine: Circle One Diabetes Thyroid disease Excessive thirst/urination Genitourinary: Urinary tract infections Painful urination Blood in your urine Difficult starting/stopping stream Incontinence Kidney stones Musculoskeletal: Broken bones Arm or leg weakness Arm or leg pain Joint pain or swelling Integumentary: Skin disease Breast pain, tenderness, nipple discharge Unusual moles-birthmarks Rash Neurological: Fainting spells or black outs Problems with memory Disorientation Difficulty with speech Inability to concentrate Double or blurred vision Weakness in arms and/or legs Loss of sensation Difficulty with balance Psychiatric: Anxiety Depression Hematologic/Lymphatic: Bleeding problems Blood transfusion Persistent swollen glands/lymph nodes Allergic/Immunologic: Food, Inhalant (nasal) allergies

Chronic Pain Patients Please identify any therapy treatment used in the past: PREVIOUS TREATMENTS FOR PAIN: TREATMENT HELPFUL? CURRENT/ONGOING COMMENTS Tens Unit? Y N Y N Y N Physical/Occupational Therapy? Y N Y N Y N Psychological Evaluation? Y N Y N Y N Who: Chiropractic Treatment? Y N Y N Y N Who: Nerve Blocks? Y N Y N Y N Who: Epidural Injections Y N Y N Y N Who: Surgeries? Y N Y N Type:

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