ORTHOSPORTS ASSOCIATES
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- Wendy Campbell
- 8 years ago
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1 ORTHOSPORTS ASSOCIATES NEW PATIENT MEDICAL HISTORY FORM DOB: Height: Weight: Race: African American Asian Caucasian Native American/Alaskan Pacific Islander Other Unknown Decline to Answer Ethnicity: Hispanic Non-Hispanic Unknown Decline to Answer Preferred Language: English Spanish Chinese Other Preferred Pharmacy: Primary Care Physician: Referral Source: Doctor (name): Other (ex. Google search): Chief Complaint Dominant Hand: Right Left Ambidextrous Description of Symptoms: (select only ONE primary symptom and ONE affected area) Pain Numbness/Tingling Fracture Stiffness Other: Shoulder Right Left Pelvis Right Left Neck Upper Arm Right Left Hip Right Left Upper Back Elbow Right Left Thigh Right Left Mid Back Forearm Right Left Knee Right Left Low Back Wrist Right Left Lower Leg Right Left Buttocks Hand Right Left Ankle Right Left Tail Bone Thumb Right Left Foot Right Left Index Right Left Great Toe Right Left Middle Right Left 2nd Digit Right Left Third Right Left 3rd Digit Right Left Little Right Left 4th Digit Right Left Pain radiates from/to: (ex. from low back to right leg) History of Present Illness 1. Is your problem the result of an injury or accident? 5th Digit Right Left No Injury Injury Injury at Work Auto Accident Sport Injury Prior Surgery How long have the symptoms been present? (ex. 2 days, 4 months) Describe the onset: Acute (sudden) Chronic condition (>3 months) Onset Date: (mm/dd/yyyy) 2. Are you represented by an attorney? Yes No Attorney Name: Will there be any legal actions with respect to this problem? Yes No 3. Have you had a problem like this before? Yes No Describe: 4. Have you been seen in an ER for this problem? Yes No Treating ER: (ex. St. Luke s Health) Date: (mm/dd/yyyy)
2 Page 2 History of Present Illness (continued) 5. Rate the pain (10 being the most pain): Do the symptoms wake you from sleep? Yes No 7. Please describe the symptoms: Sharp Dull Stabbing Throbbing Aching Burning Shooting 8. What is the timing of the symptoms? Constant Intermittent (comes and goes) 9. Is the problem getting better or worse? Getting better Getting worse Unchanged 10. What makes the symptoms worse? Squatting Kneeling Sitting Bending Stairs Twisting Moving Lying in bed Running Walking Athletics Standing Gripping Lifting Reaching Overhead 11. Are there any other symptoms associated with this problem? Redness Bruising Swelling Numbness Stiffness Limping Clicking Locking Popping Tingling Weakness Giving way Prior Testing / Treatment Have you had any prior tests for this problem? None X-rays MRI CT Scan Nerve Test (EMG/NCV) Bone Scan Have you had any prior treatment for this problem? Yes No Type of treatment Status of symptoms after treatment (select only those that apply) Date of treatment Ice Improved Worsened Unchanged Heat Improved Worsened Unchanged Rest Improved Worsened Unchanged NSAIDs Improved Worsened Unchanged Muscle Relaxers Improved Worsened Unchanged Chiropractor Improved Worsened Unchanged Physical Therapy Improved Worsened Unchanged Home Exercise Program Improved Worsened Unchanged Surgery Improved Worsened Unchanged Injections Improved Worsened Unchanged Bracing Improved Worsened Unchanged TENS unit Improved Worsened Unchanged Other/Comments:
3 Page 3 Select all previous hospitalizations/surgeries: None Aneurysm (Brain) Surgery Hysterectomy Orthopedic on side: Right Left Aortic Bypass / Vascular Surgery LAP Band / Gastric Bypass Surgery Arthroscopy: Knee Appendectomy Lumpectomy Arthroscopy: Shoulder Cataract (Eye) Surgery Mastectomy Carpal Tunnel Release Cholecystectomy (Gallbladder) Malignancy/Cancer Rotator Cuff Repair Heart Surgery Stents Total Hip Replacement Hernia Repair Total Knee Replacement Total Shoulder Replacement Spinal Surgery - Indicate Level: Other Surgery Other Orthopedic Surgery Medical Questions Mark all that currently apply: Metal in body Claustrophobic Pregnant Sleep Apnea Uses a CPAP Snores Are you taking blood thinners? Yes No Review of Systems Please indicate if you have experienced any of the following symptoms in the last 6 months? None for all None Comments 1) CON Weight Loss Loss of Appetite Fatigue 2) EYE Blurred Vision Double Vision Vision Loss 3) ENT Hearing Loss Hoarseness Trouble Swallowing 4) CV Chest Pain Palpitations 5) RS Chronic Cough Pneumonia Shortness of Breath 6) GI Heartburn, Ulcers Nausea, Vomiting Blood in Stool 7) GU Painful Urination Blood in Urine Kidney Problems 8) SK Frequent Rashes Skin Ulcers Lumps Psoriasis 9) NEU Frequent Falls Loss of Coordination Numbness Change in Bowel Change in Bladder Dizziness 10) PSY Depression/Anxiety Drug/Alcohol Addiction Sleep Disorder 11) ENDO Fever Heat or Cold Intolerance Night Sweats 12) HEM Easy Bleeding Easy Bruising Anemia
4 Page 4 Family History Have any direct relatives had any of the following disorders? None for all Father None Diabetes Heart Disease Hypertension Mother None Diabetes Heart Disease Hypertension Sibling None Diabetes Heart Disease Hypertension Social History Do you smoke tobacco? Current, every day smoker Current, some day smoker Former smoker Never Pain Diagram Heavy tobacco smoker Light tobacco smoker Do you drink alcohol? Daily Occasionally Rarely Never Marital Status: Married Single Divorced Widowed Domestic Partnership Are you currently working? Yes No Retired Disabled If no, what date did you last work? Please list work restrictions, if any: Occupation: Employer: Student Religion: Do you live alone? Yes No
5 Page 5 Do you have any allergies? Yes No If Yes, please list below: Medication, Relevant Food, or Seasonal Reaction Latex allergy? Yes No Please list all medications you take on a regular basis: None Medication Dosage and Frequency (e.g. 20 mg, once/day) Do you have a personal history of any of the following? None Aneurysm Where: Emphysema Kidney Disease Angina (Chest Pain) Epilepsy Kidney Stones Arthritis Type: Heart Attack MRSA Infection Asthma Hepatitis Type: Pacemaker Bone or Joint Infections HIV / AIDS Phlebitis (Blood Clots) Cancer Type: High Cholesterol Pulmonary Embolism Chemotherapy / Radiation Hypertension Reaction to Anesthesia Type: COPD Hyperthyroidism Seizures Congestive Heart Failure Hypothyroidism Stomach Ulcers Diabetes Type: Last A1C: Stroke / TIA Tuberculosis Please list any other conditions or details of conditions marked above: Signature Date
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WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
Interventional Spine Care New Patient History and Intake Form
Interventional Spine Care New Patient Introduction You have been referred to Dr. Hamburger/Dr. Olson. Our focus is the evaluation and management of low back pain, and other disorders of the spine. Our
MEDICAL HISTORY AND SCREENING FORM
MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems
CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident.
VANCE CHIROPRACTIC PERSONAL INJURY QUESTIONAIRE (PLEASE BE VERY SPECIFIC WITH YOUR ANSWERS THANK YOU!) Last Name First Name Middle Home Phone Work Phone Street Address and Number Mailing Address if Different
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient's Name: City: State: Zip Code: Phone: Marital Status: Spouse/Care Giver Name: Phone (H) (W) Occupation:
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
OrthoVirginia Registration Information 2016
OrthoVirginia Registration Information 2016 Patient Information Patient Name Account # Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex Male Female City, State
CALCAGNO AND ROSSI VEIN TREATMENT CENTER PATIENT INFORMATION SHEET. Last First Middle Name: Name: Initial: Male: Address: City: State: Zip:
CALCAGNO AND ROSSI VEIN TREATMENT CENTER PATIENT INFORMATION SHEET Last First Middle Initial: Male: Is this your legal name? Female: Yes / no If not, what is your legal name: Address: City: State: Zip:
TOTAL PAIN RELIEF. Also bring your medication so that we can review them with you and help answer any question you may have.
TOTAL PAIN RELIEF Dear Pain Patient, We would like to welcome you to our office. We strive to offer the best pain care with a multi-disciplinary approach. The registration and medical history forms must
PATIENT REGISTRATION
PATIENT REGISTRATION Patient s Last Name: Patient s First Name: MI: Address: City, State Zip code: Patient s Date of Birth: Patient s Social Security: Best Number to contact: Secondary Number: Marital
Motor Vehicle Accident Information
Motor Vehicle Accident Information Last Name: First Name: Social Security no.: DOB: Your Auto Insurance Company: Policy #: Policy Holder s Name: DOB: Accident Claim #: Adjuster s Name: Phone #: Ext. Attorney
Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S