Did you experience any major complications from your cancer treatment? Please describe:
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1 Cancer Rehabilitation Program New Patient Questionnaire A Collaboration of Courage Kenny Rehabilitation Institute, Virginia Piper Cancer Institute and Allina Health Please bring completed form to your appointment or fax prior to your appointment to Section One: Background Information Name: Date of Birth: Reason for appointment: Referred by: Primary Care Provider: Name, Address, & Fax: Specialty Care Providers: Names, Full Addresses, & Faxes (Please attach separate sheet if needed): Section Two: Cancer Please list all types/locations of cancer: Cancer Treatment: Please describe your cancer treatment, list types of treatment (including surgery, chemotherapy, radiation therapy or other cancer treatments). Did you experience any major complications from your cancer treatment? Please describe: Page 1 of 5
2 Section Three: PsychoSocial History Family History: Please list all family members with a history of cancer and/or swelling, what problem they each had, along with their relationship to you: Social History: Marital Status: Married Single Widowed Life Partner Employment Status: Employed Unemployed Retired What is/was your occupation? Daily Activities: Please list any activities that are performed on a daily basis (i.e. type of work, hobby, home chores, home making, etc.): Physical Activity History: Do you or have you ever exercised regularly? Describe. What would you like to be able to do for exercise? What is the one activity you cannot do now that you most wish you could do? Section Four: Medical History Have you ever had any of the following? If yes, please describe. Use additional sheet or add an attachment if necessary: I. Fevers, Fatigue, Weakness: II. Infections or immune system problems: III. Ear, Eyes, nose, throat, sinus problems: Page 2 of 5
3 IV. Cardiovascular (heart disease, hypertension, heart surgery, vein or artery disorder or surgery, coagulation disorder or therapy): V. Lung (asthma, emphysema, cancer, lung surgery, etc.): VI. Gastrointestinal including stomach, intestinal, bowel: VII. Kidney, Bladder, Urinary: VIII. Endocrine including diabetes, thyroid: IX. Skin diseases or skin conditions of any type, history of poisonous bite, rash: X. Muscular or joint problem, trauma, injury or surgery: XI. Pain or limited range of motion: XII. Neurologic problem: neuropathy, stroke, migraines, brain tumor: XIII. Difficulty walking or balancing: XIV. Difficulty with hands or dexterity: XV. Difficulty with speech or swallowing: XVI. Mental Health (depression, anxiety, chemical abuse, memory problems, hospitalizations for mental health-please include all dates): Section Five: Swelling & Edema (Fill out if you have Swelling or Edema. If no swelling, skip to Section Six) Swelling history: Please list locations of swelling: Please list approximate date of onset: Page 3 of 5
4 Has the swelling gotten better, worse, or stayed the same? What makes it get better or worse? Please list all treatments that have been tried including medications, bandages, garments, lymphedema therapy by a PT or OT lymphedema therapist. Have you ever had wounds? Please provide dates. Please provide treatment that was administered: Have you ever had cellulitis or infection related to edema? Please list approximate dates. Please include treatment including hospitalizations, antibiotics, topical preparations, creams and lotions. Have you ever had surgery or procedures performed for edema, veins, weight loss, or plastic surgical procedures? Please provide the date and result of each procedure. Have you ever had a blood clot in your arm or leg? Please list all occurrences and treatments. Page 4 of 5
5 Section Six: Meds/Allergies Medications: List all medications you take regularly or irregularly. Include over the counter medications, vitamins, supplements. Please include generic name and dosages. Attach a separate sheet if necessary. Allergies: Please list all allergies to medications and your reactions to them. How do you learn best? Discussion Reading Demonstration Visual Classroom Individual Instruction Other Signature (of Patient or person filling out the form) Date: Time: Name of person fi lling out this form if not the patient Relationship to patient Page 5 of 5
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PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
LIVING WELL An Integrative Approach to Wellness with MS Member Application
LIVING WELL An Integrative Approach to Wellness with MS Member Application Name: Date: Address: City: State: Zip: Phone: Home Work Cell E-mail address: Fax: Gender: Male Female Handedness: Left Right Both
Workers Compensation Form
Workers Compensation Form Patient Name: Job Title: Employer: What is your current work status? Working full duty Off work due to injury, since: Working light or modified duty Other: Does your job require
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
Interventional Spine Pain Consultants, P.A. Initial Consultation Information
Interventional Spine Pain Consultants, P.A. Initial Consultation Information Date: / / Date of Birth / / Age: Name: Name of the provider that recommended you to our office? Name of your primary care doctor?
Personal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
How to Remove a Social History Smoke?
AUSTIN RETINA ASSOCIATES PATIENT INFORMATION NAME: MAILING ADDRESS or NURSING HOME NAME & ADDRESS: Last First Middle Initial CITY: STATE: ZIP CODE: - TELEPHONE: HOME:( ) CELL: ( ) WORK:( ) DATE OF BIRTH: