New Patient History Inventory
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- Sophia Cook
- 7 years ago
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1 New Patient History Inventory Patient Name: Date of Birth: Appointment Date: When did your pain start? Did your pain begin gradually or suddenly? Was there any trauma or any other inciting event that caused the pain? Is this a work related injury? (Required) Y N If yes, did you file a Worker s Comp Claim? Y N Are you still working? Y N If no, when was your last day of work? Are you on disability? Y N If yes, when did you go on disability? How bad is your pain now? (Circle ONE) No pain Excruciating pain Please mark the body diagram where you feel: Ache: Burning: XXXXXXXX Numbness: Pins & Needles: //////// Stabbing: ====== Is your pain constant or does it vary based on your activity or position?
2 If your pain does vary based on your activity or position, how does the following affect your pain? Increases Decreases No effect Sitting Standing Lying down Bending Lifting Walking Coughing/Sneezing What treatments have you already had to try to manage your pain (see below)? Yes No Result? Physical therapy Chiropractic Acupuncture Injections Other (specify) Do you have any weakness associated with your pain? Yes No Explain: Does you pain wake you up at night? Yes No Overall, would you say you are (circle one): improving worsening about the same Medical History: Do you have any of the following medical conditions? Medical Y N Medical Y N Medical Y N Asthma/ Emphysema Hepatitis Parkinson s disease Tuberculosis Pacemaker Tremor COPD Heart Attack Stroke Cancer (list type): Hypertension Epilepsy/ Seizures Atrial Fibrillation Multiple Sclerosis (MS) Depression High Cholesterol Peripheral Neuropathy Diabetes Congestive Heart Failure Arthritis Thyroid (Low/ High) Irregular Heart Beat (Osteo/ Rheumatoid) Osteoporosis Murmur Acid Reflux Disease Kidney Scoliosis Sarcoidosis Stomach Ulcers Carotid disease Fibromyalgia Polio Blood/ Bleeding disease Chronic Fatigue Syndrome HIV Blood Clots/ PE Previous Surgery Previous Hospitalizations
3 Family History: Father Mother Family History Age if Age at Present Condition or Living Death Cause of Death Brothers: Number: Sisters: Number: Children: Number Check if any Relatives have had: Diabetes... Tuberculosis. Mental Illness. Heart Trouble Thyroid Trouble. Suicide. Heart Attack Arthritis.. Melanoma. High Blood Pressure. Obesity (Overweight).. Aneurysm. Stroke.... Cancer. Type: Social History: Marital Status (Please Circle One): Single Married Divorced Widowed Separated Occupation (Job): Smoking/Tobacco Use: Yes No Quit How many packs per day Pipe Cigar Chew If quit, years stopped Drink Alcohol: Yes per day per week (Circle) Beer / Wine / Liquor No Problem with Alcohol? Yes No Recreational Drugs: Yes No If yes, list drugs: Medications: Name of Medications Dosage Frequency Allergies: Do you have any allergies to medications? Yes No (no known allergies to medications) If yes, Please list medication and reaction to the medication(s): Medication Reaction
4 Please Mark a YES OR NO FOR symptoms you have RIGHT NOW CONSTITUTIONAL Yes No RESPIRATORY Yes No NEUROLOGICAL Yes No Weight Loss Cough Seizures Fatigue Coughing Blood Weakness/ Paralysis Fever Wheezing Numbness EYES GASTROINTESTINAL Tremors Double Vision Heartburn Headache Glaucoma Nausea/ Vomiting Memory Loss Cataracts Constipation Trouble finding words EAR, NOSE, THROAT Difficulty Swallowing Balance Problems Difficulty Hearing Jaundice MUSCULOSKELETAL Ringing in Ears Abdominal Pain Joint Pain/ Swelling Dizziness Black Stools Stiffness Sinus Trouble GENITOURINARY Muscle Pain CARDIOVASCULAR Pain Urinating Back Pain Murmur Frequency Neck Pain Chest Pain Nighttime Shoulder Pain Palpitations Difficulty Urinating PSYCHIATRIC Fainting Spells History Kidney Stone Anxiety/ Depression Shortness of Breath History STD Mood Swings Difficulty Lying Flat Abnormal Discharge Difficult Sleep Swelling Ankles/ Other Blood in Urine ALLERGIC/ IMMUNOLOGIC ENDOCRINE FEMALE ONLY Hay Fever/ Asthma Loss of Hair Menopause Hives/Eczema Heat/ Cold Intolerances Are Periods Regular? SKIN Change in Nails HEMATOLOGIC/ LYMPH Rash Prolonged Bleeding Lesions How did you hear about us? (Circle all that apply) 1) Referral from my physician 2) Friend/relative 3) TV ad 4) Online ad 5) Online search 6) Other: Patient Signature: Provider Signature:
5 Oswestry Disability Index Please mark the bubble next to the statement that applies to you: Section 1 Pain Intensity Section 6 Standing O I have no pain at the moment. O The pain is very mild at the moment. O I can stand as long as I want without extra pain. O The pain is moderate at the moment. O I can stand as long as I want but it gives me O The pain is fairly severe at the moment. extra pain. O The pain is very severe at the moment. O Pain prevents me from standing more than 1 O The pain is the worst imaginable at the moment. O Pain prevents me from standing for more than Section 2 Personal Care (washing, ½ an O Pain prevents me from standing for more than dressing, etc.) 10 minutes. O Pain prevents me from standing at all. O I can look after myself normally without causing extra pain O I can look after myself normally but it is very Section 7 Sleeping painful. O It is painful to look after myself and I am slow O My sleep is never disturbed by pain. and careful. O My sleep is occasionally disturbed by pain. O I need some help but manage most of my O Because of pain, I have less than 6 hours sleep. personal care. O Because of pain, I have less than 4 hours sleep. O I need help every day in most aspects of my O Because of pain, I have less than 2 hours sleep. personal care. O Pain prevents me from sleeping at all. O I need help every day in most aspects of self- care. Section 8 Sex life (if applicable) O I do not get dressed, wash with difficulty, and stay in bed. O My sex life is normal and causes no extra pain. O My sex life is normal but causes some extra pain. Section 3 - Lifting O My sex life is nearly normal but is very painful. O My sex life is severely restricted by pain. O I can lift heavy weights without extra pain. O My sex life is nearly absent because of pain. O I can lift heavy weights but it gives extra pain. O Pain prevents any sex life at all. O Pain prevents me from lifting heavy weights off the floor, but I can manage if they are Section 9 Social Life conveniently positioned (i.e. on a table). O Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are O My social life is normal and causes me no extra conveniently positioned. pain. O I can lift only very light weights. O My social life is normal but increases the degree O I cannot lift or carry anything at all. of pain. O Pain has no significant effect on my social life apart from limiting my more energetic interests, Section 4 Walking i.e. sports. O Pain has restricted my social life and I do not go O Pain does not prevent me walking any distance. out as often. O Pain prevents me walking more than 1mile. O Pain has restricted social life to my home. O Pain prevents me walking more than ¼ of a O I have no social life because of pain. mile. O Pain prevents me walking more than 100 yards. Section 10 Traveling O I can only walk using a stick or crutches. O I am in bed most of the time and have to crawl to the toilet. O I can travel anywhere without pain. O I can travel anywhere but it gives extra pain. O Pain is bad but I manage journeys of over two Section 5 Sitting hours. O Pain restricts me to short necessary journeys O I can sit in any chair as long as I like. under 30 minutes. O I can sit in my favorite chair as long as I like. O Pain prevents me from traveling except to O Pain prevents me from sitting for more than 1 receive treatment. O Pain prevents me from sitting for more than ½ O Pain prevents me from sitting for more than 10 minutes. O Pain prevents me from sitting at all. Patient name: Today s date:
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Edward M. Stroh, M.D., P.C. Retina Consultants of Long Island Page 1 Please fill out completely Legal Name First: Middle: Last: City: State: Zip: Home #: Cell #: Work #: Email: Spouse DOB DOB: Sex: SS
DEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION
DEMOGRAPHIC FORM Today s date: Dr. Doug S. Clouse Dr. Benjamin MacQueen Dr. D. Gregory Stewart Name (Last, First, MI): Home phone no.: Cell phone no.: PATIENT INFORMATION Marital status (circle one) Single
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
***************PATIENT INFORMATION****************
SEP BADY, MD ***************PATIENT INFORMATION**************** TODAYS DATE: / / WHICH DOCTOR ARE YOU SEEING? BADY KURUVILLA LIU OTTEN TRAINOR YEE PATIENT LAST NAME: FIRST: MIDDLE INITIAL: ADDRESS: CITY/STATE:
PAIN MANAGEMENT. Patient s name: IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.
PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and Reports of any X- rays, MRI or Cat scans. Patient s name:
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:
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM Today s Date: PERSONAL INFORMATION First Name: Last Name: MI: Address: City: State/Province:
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Guardian's Last Name (if patient
PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
PAST MEDICAL HISTORY REVIEW OF SYSTEMS
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
Center for Pain Management New Patient Intake Form
Patient Information Today s date: Center for Pain Management New Patient Intake Form Your completed intake paperwork helps our physicians and other providers get to know you and your medical history better.
E/M LEVEL WORKSHEET. Category. Subcategory (if applicable) (new/established, etc.)
E/M LEVEL WORKSHEET STEP 1 : IDENTIFY THE CATEGORY AND SUBCATEGORY OF SERVICE Carefully read the documentation. Using the Table of Contents, identify the appropriate category/subcategory. Category Subcategory
Height FT IN Weight Married? Y / N Employed? Y / N
Name Patient # (PLEASE PRINT) Signature Date Height FT IN Weight Married? Y / N Employed? Y / N Previous Illnesses: Check all that apply AIDS, HIV, STD Epilepsy Pacemaker Alcoholism Eye/vision problems
Patient Information Form Pain Management Center at Phoebe
Patient Information Form Pain Management Center at Phoebe Please complete the following form, so that we may facilitate your visit Occupation: or (circle) Retired, Disabled Homemaker, Full time student
Welcome to Active Care Atlanta
Welcome to Active Care Atlanta Name Birth Date Age Male Female Cell # Home # Work # Address City, State & Zip Email Occupation Employer Social Security # - - Marital Status Single Married Divorce Other
FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA
PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING
Surgery Health Survey
Surgery Health Survey Name: Social Security Number: Date of Birth: Please tell us which physician(s) we should contact regarding your visit: REFERRING PHYSICIAN Name: Address: PRIMARY CARE PHSYICIAN Name:
Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork.
Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork. So we may eliminate any potential waiting time, please fax the completed forms
MEDICAL HISTORY INFORMATION
MEDICAL HISTORY INFORMATION Name: Birthdate: Age: Address: Home Telephone: Cell Telephone: Work Telephone: Social Security Number: Marital Status: Single Married Divorced Widowed Spouse s Name: Birthdate:
1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074
Locations 1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074 2 East 328 S. Woodcrest Drive, Bloomington, IN 47401 t 812.353.3278 866.353.3278 3 West 2499 W. Cota Drive,
PATIENT HEALTH QUESTIONNAIRE: Urology
PATIENT HEALTH QUESTIONNAIRE: Urology Patient Name: Sex: M F Last, First, Middle Initial Email: Date of Birth: \ \ Age: Social Sec #: - - Type of visit: Consultation requested by another Physician Self-referred
COMPREHENSIVE SPINE CENTER
Dear Esteemed Patient: CSC Physicians: Ulrich Batzdorf, MD; David E. Fish, MD; Langston Holly, MD; Jae Jung, MD; Duncan Q. McBride, MD; Don Y. Park, MD; Nick Shamie, MD; Daniel Lu, MD, PhD COMPREHENSIVE
NORTHEAST SPINE & SPORTS MEDICINE PATIENT INTAKE MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE#: CELL#: WORK PHONE#: S / M / D / W
NORTHEAST SPINE & SPORTS MEDICINE PATIENT NAME: PATIENT INTAKE SOCIAL SECURITY#: SEX M/F: DATE OF BIRTH: AGE: MAILING ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: HOME PHONE#: CELL#: WORK PHONE#: EMPLOYER: