Personal Medical History. Why are you here today? What symptoms are you having now? When did they start?
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1 Personal Medical History Patient Name: Date of Birth: Why are you here today? What symptoms are you having now? When did they start? What conditions are you currently being treated for (by any physician)? What is your marital status? Single Married Divorced Separated Widowed What is your primary language? What is your highest educational grade completed? Do you have any barriers to learning? Do you smoke? Yes No Pipe Cigars Cigarettes Start Date: Quit date: Do you drink alcohol? Yes No Beer Wine Liquor How many drinks per day or week? History of alcohol abuse date(s): History of drug abuse date(s): Have you experienced any of the following? Birth Injury date(s): Serious Illness as an infant date(s): Serious Illness as a child date(s): Skin Cancer date(s):
2 Have you had any illnesses in the following categories? Please indicate any problems/surgeries by check mark. Please include dates and details. Head/Brain Stroke Migraine Seizures Dementia Head Injury Loss of Consciousness Ears Deafness: Right Left Both Hard of Hearing: Right Left Both Hearing Aid: Right Left Both : Right Left Both Eyes Blindness: Right Left Both Glaucoma: Right Left Both Cataracts: Right Left Both Injuries: Right Left Both : Right Left Both : Nose Decreased smell Deformity
3 Throat Difficulty swallowing Difficulty speaking or low speech Lungs Asthma Breathing problems/shortness of breath Heart High cholesterol or lipids Congestive heart failure Heart attack Mitral valve prolapse Heart murmur High blood pressure Gallbladder or Liver Gallstones Reproductive Hormone replacement therapy Breast lumps or surgeries Sterility: Surgical or Non-surgical? Menopause Impotence
4 Prostate trouble Stomach/Intestines Reflux disease Ulcers Constipation Diarrhea Incontinence Kidneys/Bladder Kidneys stones Urinary infections Urinary frequency/urgency Inability to urinate Incontinence Skin Rashes Cysts Cancer
5 Muscles/Bones Numbness, tingling Neck pain Back pain Osteoporosis Arthritis Fractures Psychological Anxiety Depression Insomnia Mental illness Decreased concentration Confusion Disorientation Dementia Alzheimer s Disease Sleep disorder Hallucinations Medical Conditions: Cholesterol Thyroid Diabetes Obesity
6 Allergies Please list any non-medication allergies and reaction type Cancer Have you ever been diagnosed with cancer? Yes No Type: Treatment: Radiation: Chemotherapy: Date: Pain Please indicate any pain you are having by checking the number that best describes it. Happy Has No Pain Hurts a little bit Hurts a little more Hurts even more Hurts a whole lot Hurts as much as you can imagine No pain Mild pain Moderate pain Severe pain Very Severe Worst Possible Where is your pain? How long have you had it? What do you take for it? What doctors have you seen for it? Are you: Right handed Left handed Ambidextrous (both)
7 Family History: If a family member has had any of these conditions, please enter age of onset if known Age of Onset Alzheimer s Disease Cancer Diabetes Dystonia Encephalitis Head Injury Heart Disease Huntington s Disease Parkinson s Disease Seizures Stroke Tourette s Syndrome Tremor If living, indicate age and current state of health: Age Current State of Health Father Mother Brother Sister Children If deceased, indicate age and cause of death: Father Mother Brother Sister Children -please indicate relationship Father Mother Brother Sister Children Age Cause of Death
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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 ( )
RETINA CARE CENTER, P.C. PATIENT INFORMATION
RETINA CARE CENTER, P.C. JONATHAN M. BAROFSKY, M.D., F.A.C.S. Parkway Seventy Plaza 1255 Route 70, Suite 31N Lakewood, New Jersey 08701 PHONE (732)905 0004 FAX (732)905 3868 PATIENT INFORMATION Welcome
Cervical Spine. New Patient Form
Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right
Patient Information. Today s date: Your Name: Social Security Number: Date of Birth: Age: Height: Weight: lbs. Street Address: City/State/Zip:
Welcome to Avenstar Pain Specialists! Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best