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Transcription:

Please print # Date: Last Name: First Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Email address: Date of Birth: Sex: M F Social Security #: Employer name: Occupation: (if a minor, head of household employer) Employer address: Phone: If married, spouse s name: Spouse s employer: Phone: Type of Patient and/or payment method (circle one) NF Auto Accident (No-Fault) PI Personal Injury Case WC Employment Injury (Workers Compensation) MM Major Medical Insurance C Cash payment MR Medicare Referred to this office by: Emergency contact: Name: Phone: I hereby authorize the office of Dr. Maria Perri to release information concerning my examination and/or treatment. I authorize payment directly to this office for professional services, and I understand that I will be directly responsible for any unpaid balance. Signature: Date:

Select one answer in each of the columns below: Occupation Marital Status Education Level Professional/Technical Married Less than 12 years Tradesman Widowed High School Clerical Separated 1-4 years of college Homemaker Divorced Beyond 4 years of college Production Never married Professional school Service/Retail Other Do you NOW have any of the following conditions? (mark if YES) Congestive heart failure Sciatica or chronic back problem Chronic lung disease (including bronchitis or emphysema) Hypertension or high blood pressure Blindness or trouble seeing, even when wearing glasses Angina Deafness or trouble hearing Heart attack or myocardial infarction Sugar diabetes (diabetes mellitius) Type 1 Stroke Sugar diabetes (diabetes mellitius) Type 2 adult onset? Kidney disease Asthma Cancer Ulcer or gastrointestinal bleeding (not counting hemorrhoids)? Depression Arthritis or rheumatism Other Do not smoke or If you smoke cigarettes, how many do you smoke in an average day? Less than 1/2 pack 1/2 pack 1 pack 1 2 packs over 2 packs Do not drink or if you drink alcohol, about how many drinks in an average day? Less than 1 drink no more than 1 1 or 2 drinks 3 5 drinks 6 8 drinks more than 8 drinks Are you taking any medications? no yes If yes, please specify: If female, are you pregnant? Please list any operations, bad falls, broken bones, or injuries from childhood to present: Check any symptoms you have or have had in the past six months: Headaches Mid back pain Neck pain Lower back pain Shoulder pain Hip pain Arm pain Leg pain Hand numbness Foot numbness Arthritis Dizziness Sinus problem Knee numbness Nervousness/tension Allergies General stiffness High blood pressure Anxiety/stress Stomach problem Clicking jaw Other:

How would you describe your chief complaint at this time? When did it start? Date (include at least month and year; day if known) What is your history with this injury? Sudden trauma Reoccurrence Repetitive trauma What makes the pain worse? What makes the pain better? How would you describe the pain? Where is the pain located? At what time of day or week is your pain worst? The pain is: The pain is Constant - or - Intermittent and it usually lasts for minute(s) hour(s) day(s) week(s) How long have you been How many times have you When did you first have having pain? had this problem in the past? these or similar symptoms? 1 week or less Never Never 1-6 weeks 1-3 episodes < 6 months ago > 6 weeks, but < 3 months 4 or more episodes 6 months 1 year ago 3 months 1 year More than 1 year ago Over 1 year Motor Vehicle Accident Is your pain the result of a motor vehicle accident? yes no Location of impact Rear end Frontal Side Both front and rear Both front and side Both side and rear Job Injury yes Is your pain the result of a work related injury? Have you been disabled from working because of pain during the past year? Have you filed a workman s compensation claim? Disabled from To Personal Injury yes Is your pain the result of a personal injury outside of work or a motor vehicle accident? Have you filed a legal suit?

Date: Last Name: First Name: Please use the following descriptive symbols on the body outlines below to describe the location of your problem. In addition, mark the level of your pain on the pain line at the bottom of the page. Ache Burning Numbness Pins & Needles Stabbing Other ^^^^^ ====== 0000000 ///////////// xxxxxx Please check the box at the level that most accurately represents your pain: 0 1 2 3 4 5 6 7 8 9 10 Right now: No pain Unbearable Average pain: No pain Unbearable At best/worst: No pain Unbearable

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