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

Similar documents
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)

Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State

Patient Name: Date of Birth:

New Patient Intake Form

Welcome to Medina Family Chiropractic and Acupuncture!

Where is your pain located? Please use the diagram below to indicate where most of your pain is located.

CORNERSTONE PAIN MANAGEMENT

Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week

GUPTA SPORTS & SPINE CENTER

WELCOME to the Florence Chiropractic and Wellness Center.

Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)

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

Aspire Pain Medical Center

*** ADDRESS: (If address is not provided, you MUST write Patient denied.)

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

o Kidney Cancer o Liver Cancer o Tremor o Tuberculosis o B12 Deficiency o Esophageal Cancer o Liver Disease o Pituitary Tumor o Uterine o Neurological

Patient Information. Insurance Information

Patient Interview Form

\ NSMI. The National Sports Medicine InstJtute

Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:

Initial Pain Management Patient Questionnaire

PATIENT INFORMATION FORM

Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B

Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone

Emergency Contact Name Relationship Phone Primary Care Physician Phone Did a Physician Refer you to us? YES NO Physician Name

NEW PATIENT INFORMATION FORM

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

HEALTH QUESTIONNAIRE

WASHINGTON UNIVERSITY SCHOOL OF MEDICINE. Cranial Health History Form

* CC* PATIENT QUESTIONNAIRE

The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:

New Patient Information and History Form

Patient s Name Date: Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other

PAIN TREATMENT CENTER

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

Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:

I choose not to specify

Patient Name Date MR#: FLORIDA ORTHOPAEDIC INSTITUTE. Race: Ethnicity: (Circle one) Hispanic / Not Hispanic

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

Eastern Shore MediCann Clinic, LLC

Rise Chiropractic 239 S. French Broad Ave Asheville, NC

Kish Chiropractic 320 West Main Street Mount Horeb, WI

Past Surgical History

PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: Internet: Fax:

Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: Address: Relationship: Address:

Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone

GUPTA SPORTS & SPINE CENTER

Chiropractic Case History/Patient Information

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

ANY FAMILY HISTORY OF ANEURYSM OR DVT?

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

Last Name First Name MI: Address City State Zip. Referring Provider. Employer Address. Emergency Contact Relationship Phone. ID # Group # ID # Group #

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

PAIN INFORMATION SHEET

Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female

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

MEDICAL HISTORY. Previous Nephrologist. Medication taken Insulin Oral Both. Who manages your diabetes? Blindness Yes No Hearing Problems Yes No

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

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?

Chiropractic Registration and History

New Patient Information

DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT

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?

Pacific Coast Medical Group, PLLC dba Bellevue Pain Institute NE 8th St. Ste. 200 Bellevue, WA

Patient Interview Form

NEW PATIENT INFORMATION

NEW SPINE PATIENT. Date Seen: Blood Pressure: Pulse: Weight: Height: O 2. How long (days, weeks, or years) has this complaint/problem been going on?

Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:

Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:

Saleeby Chiropractic Centre, P.A.

PATIENT NAME DATE CONSULTATION QUESTIONNAIRE

FROST FAMILY MEDICINE

MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History

Primary Care Physician: If Yes, where? Current work status: Full-Time Part-Time Self-Employed Unemployed Disability Retired

Adult Demographics Form

Patient Registration Form

Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:

Patient Interview Form

Patient Information. Legal Name: First Middle Last. Street City State Zip

Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:

PATIENT INFORMATION FORM (PLEASE PRINT)

Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:

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

New Patient Pain History Form

PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

LECOM Health Ophthalmology

New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification

1. What is your chief complaint? Why are you seeking physical therapy treatment? 2. Explain how and when your injury/symptoms occurred:

Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone

Amarillo Surgical Group Doctor: Date:

Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:

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

Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C

COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:

Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:

History of Present Problem

Notto Chiropractic Health Center Patient Information

Transcription:

Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / / Email Address: Do not have email Do not wish to provide Date of Birth: / / Gender: Male Female Social Security Number / / Emergency Contact: Relationship: Home Phone: / / Cell Phone: / / PCP Physician: Referring Physician: Marital Status: Single Married Separated Divorced Widowed Employment: Employed Unemployed Disabled Retired Employer: Occupation: Employer Address: Guarantor (if patient is under 18 Relationship: Home Phone: / / Cell Phone: / / Is this a: Workers Compensation Injury Accident Related Injury Neither Primary Insurance Carrier: Policy #: Group #: Subscribers Name: Subscribers Date of Birth: / / Relationship to Patient: Secondary Insurance Carrier: Policy #: Group #: Subscribers Name: Subscribers Date of Birth: / / Relationship to Patient:

Name of Pharmacy: Address: City: State Zip Phone #: / / PLEASE READ THE FOLLOWING DOCUMENTS AND INITIAL BELOW: (initial) (initial) (initial) I have reviewed the Statement of Financial Policy I have reviewed the Patient Rights and Responsibilities I have reviewed the HIPPA Information and Consent Form Language: English Spanish Other Refuse to Report Race: Black or African American White Hispanic Other Race Refuse to Report Ethnicity: Hispanic or Latino Not Hispanic or Latino Refuse to Report If you would like information to be obtained by family members, friends, etc please list those below. If you do not have anyone listed below they will not be able to call into our office for information regarding your care including your appointment date or time. I authorize release of information to the following: NAME Relationship NAME Relationship NAME Relationship I hereby consent to and authorize The Pain Center to apply the benefits on my behalf for the services rendered by Dr. Baksh and Staff. I request payment from my insurance or responsible party be made to The Pain Center. I certify that all information I have provided is correct to the best of my knowledge. I authorize the release of any medical information for this claim or any related claim. I permit a copy of this authorization be used in place of the original. I may revoke this authorization at any time in writing. I understand that nothing herein relieves me of the primary responsibility and obligation to pay the medical services proved to me. I understand that payment is due when the statement is rendered. Patient/Guardian Signature: Date: / /

Chief Complaint Smoking Status (circle) Current every day smoker Current some day smoker Former smoker Never smoked What is your usage per day? Alcohol Use (circle) Non-drinker Drink socially Drink daily History of alcohol abuse How much do you drink per week? Illicit Drug Use Do you use any illicit drug? Yes No If yes, please specify Marijuana Cocaine Heroin Methamphetamines Opioids Inhalants Other: Location of pain. Draw X to indicate areas of deep pain. Draw Z to indicate areas of tingling and numbness. Use arrows to show areas that pain or tingling radiates/travels.

Frequency of pain Constant Intermittent (comes and goes) Description of pain Aching Burning Radiating Pain Sharp Shooting Electric Like Stabbing Dull Deep Tingling Severity Minor Moderate Severe Pain Intensity Rate your pain on a scale of 0 to 10 (0 is no pain and 10 is the worst pain possible) Duration and Onset of Pain How long have you had this pain? Specify days, months or years (example 6 months or 1 year) Describe how your pain started Gradual Sudden Triggered If triggered please explain (example if pain was caused by a fall or car accident, etc.) What makes your pain worse? Twisting Sneezing Coughing Touch of Skin Standing Sitting Bending Forward Bending Backward Walking Exercise Cold Heat Stress Other: What makes your pain better? Standing Sitting Bending Forward Bending Backwards Walking Medications Exercise Injections Cold Heat Rest Change Positions Frequently Other:

What treatments have you tried for your pain? Medications Physical Therapy Acupuncture Injections TENS Unit Chiropractic Care Pain Management Service Elsewhere Psychology/Counseling Please specify your response (examples list names of medications tried, name of previous pain management, type of injections, etc.) Are any of the following symptoms associated with your pain? Numbness Swelling Joint Pain Muscle Pain Tingling Nausea Palpitations Dizziness Vomiting Seizures Fainting Shortness of Breath Radiating Pain Are you allergic to any medications, food, etc. Please specify (example Penicillin causes rash) Are you currently taking a blood thinner medication for a blood clotting disorder? Yes No If yes, specify the name of medication Please list ALL the MEDICATIONS you are CURRENTLY taking. Specify the name, dose and frequency (example Ibuprofen 800mg two times daily). You may also attach CURRENT MEDICATION LIST. Medication Name Dose Frequency

Family Medical History. Please list any family medical problems (example diabetes, heart attack, stroke, type of cancer, etc.) Father: Mother: Sister(s): Brother(s): Past Surgical History: Angioplasty Coronary Artery Stent Coronary Artery Bypass Graft Pacemaker Carotid Endarterectomy Appendectomy Gastric Bypass Cataract Extraction Tonsillectomy Adenoidectomy Hysterectomy Fracture Repair (specify where the fracture was located) Arthroscopy (specify the joint and the side) Joint Replacement (specify the joint and the side) Have you ever had surgery on your spine? Yes No If yes, please specify the location of the spine Cervical (neck) Thoracic Lumbar Please list any other surgeries you have undergone What diagnostic testing have you undergone related to this pain? MRI CT Scan XRAY Nerve Conduction Study Please specify the name of facility where testing was done:

In the past have you had any of the following medical problems? (Please check all that apply to you.) Cardiovascular Arrhythmia (irregular heartbeat) Coronary artery disease Congestive heart failure Hyperlipidemia (high cholesterol) Hypertension (high blood pressure) Myocardial infarction (heart attack) Poor circulation Other Gastrointestinal Cholelithiasis (gallstones) Cirrhosis Colon polyps GERD (gastroesophageal reflux disease, indigestion) Peptic ulcer disease Other Musculoskeletal/Connective Tissue Chronic pain Specify Fibromyalgia Fractures Specify: Osteoarthritis Osteoporosis Rheumatoid arthritis Other Neurologic Carotid stenosis CVA (stroke, TIA) Headaches Multiple sclerosis Parkinson's disease Seizure disorder Pulmonary Asthma COPD (chronic obstructive pulmonary disease) Chronic bronchitis Tuberculosis Renal/Genitourinary BPH (benign prostatic hypertrophy) Endometriosis Kidney disease or stones Renal failure Urinary incontinence or retention Endocrine Diabetes Type I Type II Hyperthyroidism Hypothyroidism Hematologic Anemia Psychiatric Anxiety Bipolar disorder Depression Obsessive/Compulsive disorder Post-traumatic stress disorder

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