Patient Name Date of birth today s date. Weight left or right handed. Attorney name: Referred By:
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1 Auto Accident Check In NEW PATIENTS Patient Name Date of birth today s date Height Weight left or right handed Date of accident: Cell Phone Attorney name: Referred By: Auto Accident details: Please circle all that apply Patient was: Restrained Patient was: Driver not restrained front seat passenger back seat passenger Please indicate type of vehicle and speed of vehicle for each involved: Vehicle # 1(patient) Vehicle # 2 Vehicle # 3 Vehicle # 4 Location of accident Patient s car was: Rear-ended t-boned on right t-boned on left struck head on Other vehicle ran light or stop sign other Did air bags deploy? Injury to head: YES/No Loss of consciousness: First recollection after loss of consciousness Did patient strike any other body part? If yes, please describe: Symptoms at the scene of accident: Evaluated by Emergency personnel at the accident scene: Transported by Emergency personnel: Transported by other means: Transported to:
2 X-rays/MRI/Diagnostic testing: Meds given in ER: N-SAIDS Pain Medication Muscle relaxer Name of medications Follow up care: PCP Chiropractic Physical therapy Name of physician: Details of other accidents: any other accidents, slip and fall, work comp, etc. Status of prior injuries: resolved permanent chronic Today s injuries/symptoms: Neck Injury: new or aggravated no pain extreme pain Mid-back: new or aggravated no pain extreme pain Low-back: new or aggravated no pain extreme pain
3 Headache: new or aggravated no pain extreme pain Headache pain location: front side back Extremity involvement: Circle all that apply: Left arm Pain numbness tingling burning no symptoms area of arm Right arm Pain numbness tingling burning no symptoms area of arm Left leg Pain numbness tingling burning no symptoms area of leg Right leg Pain numbness tingling burning no symptoms area of leg Misc. changes: please circle any changes that occurred after your accident: Memory concentration Dizziness Balance Blurry vision Jaw pain Ringing in eras nausea speech smell swallowing increased anxiety Increased Depression difficulty walking Current treatment: Physical Therapy Pain Management Chiropractor Neuropsych Neurosurgery Dates of treatment or surgery
4 Name of other physicians/chiropractors/therapists/surgeons/hospitals Current Medications: Preferred pharmacy: Please include name, address, and phone number: Review of systems: Please circle all that apply General: fever chills fatigue night sweats out of country travel recent weight gain Cardiovascular: chest pain on exertion shortness of breath palpitations swelling orthopnea Respiratory: chest pain when breathing cough wheezing spitting of blood Gastrointestinal: Constipation diarrhea hepatitis blood loss peptic ulcer disease Genitourinary: frequent urination dysuria hematuria history of stones Musculoskeletal: joint pain joint stiffness joint swelling weakness of muscles arthritis Endocrine: diabetes dry skin changes in hair Psychiatric: depression anxiety bipolar disorder schizophrenia other psychological problems Hematologic/lymphatic: anemia past transfusions Skin: allergy eczema hives change in skin color change in hair/nails rashes Suspicious bug/mosquito/tick bite Other: pregnant contemplating pregnancy using birth control
5 Past Medical history: Past surgical history:
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SOUTHEASTERN SPORTS MEDICINE Page 1 of 6 21 Turtle Creek Drive Asheville, NC 28803 DATE PATIENT INFORMATION PATIENT NAME: Last First Middle ( ) Child ( ) Single ( ) Married ( ) Widow(er) ( ) Divorced Address
CALIFORNIA PACIFIC ORTHOPAEDICS & SPORTS MEDICINE PATIENT REGISTRATION FORM
CALIFORNIA PACIFIC ORTHOPAEDICS & SPORTS MEDICINE PATIENT REGISTRATION FORM WILLIAM L. GREEN, MD JON A. DICKINSON, MD JOHN P. BELZER, MD KEITH C. DONATTO, MD PETER W. CALLANDER, MD CHRISTOPHER COX, MD
Patient Basic Information
Patient Basic Information Personal Information: Last Name: First Name: Mid. Init.: Address: City, State, Zip: Home Phone: Work Phone: Social Security No.: Date of Birth: Date of Injury/Onset: Dominant
Addiction Medical Clinic LLC
Chief Complaint and Symptom: Substance Abused: Current amount per use and Frequency/day used: Last use: Date & Time: Route: Current and in the past: Duration of Use: Both Current and Lifetime: Have you
LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic