ANNUAL PATIENT QUESTIONNAIRE. Name: Age: DOB: Date: Referring Physician: Primary Care Physician: Height: Weight: Are you: Right handed Left handed
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1 ANNUAL PATIENT QUESTIONNAIRE Name: Age: DOB: Date: Referring : Primary Care : Height: Weight: Are you: Right handed Left handed HISTORY: (please circle) Chief Complaint: How long have you had this pain:? Where is your pain located? Does this pain radiate into arms, legs, buttocks, etc? Did anything specific happen to cause the pain? Do you feel any weakness, tingling, Numbness or stiffness? Please describe your pain (sharp, burning, pressure, etc): Any other symptoms with the pain (i.e. headaches, loss of bowel or bladder, etc)?: _ What makes the pain better? What makes the pain worse? How severe is your pain (scale 0-10)? 0 Absent (No pain); 1-2 Tolerable (tolerate without medications); 3-4 Bearable (some activities restricted/prevented, requires medication); 5-6 Nearly intolerable (sedentary, only able to watch TV, read, etc.); 7-8 Intolerable (Can t read, watch TV, use the phone, need to visit ER for pain killers); 9-10 Devastating (need hospitalization for pain control) (please draw a line through where you feel your 0 10 your pain is best represented) Have you been treated by other clinicians for this problem? YES NO (please circle) If yes, please list name, date seen, and treatment given: Have you had any physical therapy (PT)? YES NO (please circle) How many sessions? Has PT helped? YES NO (please circle) Have you had epidural or facet injections? YES NO (please circle) How many? Did they help? YES NO (please circle) Have you had a previous back or neck surgery? YES NO (please circle) Have you had diagnostic tests performed?(ct, MRI, EMG, etc.) YES NO (please circle) If yes, please list:
2 Please mark the figure with the location of your symptoms: Pain=XX Numbness/Tingling=OO Are you having difficulty with sleep because of your pain? How long can you: Sit Stand Walk Have you lost any control over bowel or bladder functions? YES NO (please circle) Is your pain related to a specific injury? YES NO (please circle) If yes, please describe: Is the injury or pain the result of a work related injury? YES NO (please circle) If yes, what is the date of injury? Have your reported it to your employer? Yes No Is the injury or pain motor vehicle related? YES NO (please circle) If yes, what was the date of your accident? Is there a lawsuit (pending or considered)? N/A YES NO (please circle) What do you hope to accomplish today?
3 MEDICATIONS: Please list all medications you are currently taking. (Including any over the counter medications. Be sure to list if you are taking any form of aspirin.) List medications that you have taken in the past and if they did or did not help: Medication allergies? YES NO (please circle) Please list: Do you have any other known allergies? YES NO (please circle) Please list: PHARMACY Please list the name, address, and phone number of the pharmacy you use: PAST SURGICAL HISTORY: Please list any previous surgeries: FAMILY HISTORY: Please list any medical illnesses that the following blood relatives have a history of: Grandparents: Father: Mother: Brothers/Sisters: SOCIAL HISTORY: Marital Status: Single Married Divorced Separated Widow (please circle) Number of children Ages Do you smoke? No Yes How much? For how long? Previous Smoker? No Yes When did you quit? Do you drink alcohol? No Yes How many drinks per week? Do you use recreational drugs? No Yes If yes, what type: WORK HISTORY: Are you working? YES NO (please circle) If so, Full-time Part-time Restricted Duty If restrictions, please describe: If not, date last worked: Occupation: Employer: How long in position?
4 REVIEW OF SYSTEMS: Please mark an X for Yes and leave blank for No. CONSTITUTIONAL: I have none of the symptoms listed Fever Chills Fatigue Night Sweats Unexplained weight Gain/Loss SKIN: I have none of the symptoms listed Rashes Nail changes Easy Bruising Color changes Jaundice Infections EYES/EARS/NOSE/THROAT: I have none of the symptoms Listed Vision changes Hearing Loss Dizzines/Vertigo Ringing in the ear Hoarseness Difficulty Swallowing Discharge/Drainage CARDIOVASCULAR: I have none of the symptoms listed Chest Pain Palpitations Leg Swelling RESPIRATORY: I have none of the symptoms listed Coughing up blood Wheezing Shortness of Breath Cough Sputum Production Recent Infection GASTROINTESTINAL: I have none of the symptoms listed Abdominal pain Vomiting w/wo blood Nausea Blood in stool Constipation Diarrhea GENITOURINARY: I have none of the symptoms listed Painful urination Blood in urine Venereal Disease Difficult urination Sexual problems Menstrual Problems Pregnant Menopausal MUSCULOSKELETAL: I have none of the symptoms listed: Joint swelling Stiffness Cramping Infection ENDOCRINE: I have none of the symptoms listed Changes in urination Changes in heat or cold intolerance Changes in appetite/thirst/sweating PSYCHIATRIC: I have none of the symptoms listed Depression Anxiety Suicidal Thoughts Mood Changes
5 PAST MEDICAL HISTORY Illness/Condition Is your Primary Care Doctor the Treating If No, please list Treating Name Is problem Stable/ Well Controlled Please Check Yes No Yes No Yes No If No, Please Explain Sleep Apnea Anxiety Depression Psychiatric Problem Asthma Pneumonia Lung Disease Pulmonary Embolism Heart Disease Heart Murmur Heart Attack High Blood Pressure Anemia High Cholesterol Bleeding Disorder Deep Vein Thrombosis GERD Ulcers Rheumatic Fever Liver Disease/Hepatitis Alcoholism Arthritis Muscle Disease Thyroid Disorder Gout Diabetes Migraines Seizure Disorder Stroke Osteoporosis HIV/AIDS Kidney Disease Tuberculosis Rheumatoid Arthritis Psoriasis MRSA Other (Please explain)
6 Cancer History Is your Primary Care Doctor the Treating If No, please list Treating Name Is problem Stable/ Well Controlled Please Check Yes No Yes No Yes No Leukemia Breast Cancer Cervical Cancer Prostate Cancer Ovarian Cancer Throat Cancer Bone Cancer Skin Cancer Lung Cancer Cancer (other) please explain. If No, Please Explain PATIENT SIGNATURE Date: PHYSICIAN SIGNATURE Date:
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Rehabilitation Medicine Clinic (Please complete this 5-page form and bring to your appointment.) Date Appt. Date Age Date of Birth Name Male Female Hand dominance: R L Home Address Home Phone ( ) Work
A photocopy of this document shall be considered as effective and valid as the original.
p In order for us to obtain a complete medical history, it is important for you to fill out this form in its entirety. Every item needs to be filled out. This information will be entered into our Electronic
Personal Injury Questionnaire
Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer
WORKER S COMPENSATION HISTORY FORM NAME (Last, First, Middle Initial) Height Weight
341 Magnolia Avenue, Suite 101 28078 Baxter Road, Suite 330 Corona, CA 92879 Murrieta, CA 92563 (951) 735-6060 (951) 735-4510 Fax (951) 677-2157 www.ctoamg.com WORKER S COMPENSATION HISTORY FORM NAME (Last,
CLINIC APPLICATION. Client Information
ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone
Princeton and Rutgers Neurology, P.A. A Center Of Excellence
DEMOGRAPHICS Patient s Last Name: First Name: Address: City: State: Zip Code: Tel # (Cell): Tel # (Home): Tel # (Work) #: Preferred Method Of Contact: [] Cell Phone [] Home Phone [] Work Phone SS #: /
Welcome to the UW Health Sports Medicine Clinic
Welcome to the UW Health Sports Medicine Clinic You are scheduled on to see. In order to best serve your needs, please bring with you to your appointment the following: 1. Completed Questionnaire (enclosed)
Orthopedic Specialists Of SW FL New Patient Information Form
Orthopedic Specialists Of SW FL New Patient Information Form Patient Name: DOB Age M or F SS# Home Ph# Cell Ph# Work# Local Address City/State Zip Code Northern/Other Address City/State Zip Code Reason
Insured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS:
Luna Spine and Orthopaedic Surgery Mario E. Luna, MD
PATIENT INFORMATION NAME (Last, First, Middle Initial) PRIMARY ADDRESS PATIENT REGISTRATION FORM EMERGENCY CONTACT NAME (Relationship to Patient) CITY, STATE, ZIP CITY, STATE, ZIP PHONE ( ) HOME ( ) CELL
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR PATIENTS WITH WORK RELATED INJURY (Please complete this form and bring it with you on your visit)
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR PATIENTS WITH WORK RELATED INJURY (Please complete this form and bring it with you on your visit) Last name: First Name: Title: Mr. Mrs. Dr. Appt Date: Primary
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081 PLEASE COMPLETE ALL OF THE INFORMATION. REFERRED BY: LAST NAME MIDDLE FIRST STREET ADDRESS CITY STATE ZIP CODE HOME PHONE ( ) - WORK ( )
Medical Massage Client Intake Form Medical Massage Client Intake Form
Medical Massage Client Intake Form Medical Massage Client Intake Form Client Name: Date: Please note: The more information you are able to provide, the better equipped our therapists will be to help you.
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVERS LICENSE NUMBER: STATE: EMAIL ADDRESS: MARITAL STATUS: ( ) SINGLE ( )