SPINE PATIENT HISTORY FORM
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1 Trenton Orthopaedic Group 116 Washington Crossing Road 1225 Whitehorse-Mercerville Road Pennington, NJ Bldg. D., Suite 220 Mercerville, NJ SPINE PATIENT HISTORY FORM Please print all information. All blanks must be filled so that we may serve you more quickly and efficiently. Please use the back of the forms if you need more space. Thank you for your cooperation. DATE: DATE OF BIRTH: PATIENT NAME: ADDRESS: HOME PHONE: ( ) HEIGHT: WORK PHONE: ( ) WEIGHT: HOW WERE YOU REFERRED TO OUR OFFICE? REFERRING PHYSICIAN: ADDRESS: PHONE #: ( ) FAX#: ( ) Are there any other physicians that should need copies of your records? Please include name and address: 1. Where do you have pain? (Circle any area that applies to you) Neck Low Back Upper Back Abdomen Right Shoulder Right Arm Right Forearm Right Hand Left Shoulder Left Arm Left Forearm Left Hand Right Buttock Right Thigh Right Leg Right Foot Left Buttock Left Thigh Left Leg Left Foot Other: 2. How long have you had your pain? 3. Specific date when your pain started: 4. How did your pain begin? (If your complaints are the result of an injury, exactly what happened and where did this occur? 1
2 5. Is this a worker s compensation case? Yes No 6. Is legal action underway or contemplated? Yes No What is your lawyer s name and phone number? 7. Have you had any back or neck problems in the past? Please explain and describe the problems and treatments? 8. Is there a family history of back or neck problems? Please be specific 9. Have you had any previous spine surgery? If yes, please fill in below. Procedure: Name of Surgeon: Date of Surgery: 10. For how long did you feel improvement following the surgery: If no improvement, what complaints remained after the surgery? CURRENT PAIN PROFILE 11. How would you describe your pain ratio? (Check one) 100% back/neck pain and 0% leg/arm pain 75% back/neck pain and 25% leg/arm pain 50% back/neck pain and 50% leg/arm pain 0% back/neck pain and 100% leg/arm pain 12. Please describe your pain in your own words. 13. Does the pain wake you up after falling asleep? Yes: No: 2
3 14. Please answer the following questions using the following chart: A. Unable to tolerate How long can you sit? B. About 15 minutes only How long can you stand? C. About 30 minutes only How long can you walk? D. About 45 minutes E. About 1 hour F. Indefinite 15. Which of the following activities change the nature of your pain: Aggravates Relieves Pain Pain Neither Sitting Standing Rising from sitting Leaning forward Walking Lying on your side Lying on your back Lying on your stomach Driving Coughing/Sneezing Bending forward NOW, GO BACK AND CIRCLE THE BOX TO INDICATE THE MOST AGGRAVATING ACTIVITY AND THE MOST RELIEVING ACTIVITY. TREATMENT ATTEMPTED FOR CURRENT PAIN 16. Using the following list of treatments, please indicate the effect of those which have been used in an attempt to heal your present injury. HELPFUL NOT HELPFUL NOT USED Back School Hot packs Ice TENS unit Traction Physical Therapy Exercise Program Brace/collar Acupuncture Chiropractor Epidural Block Facet blocks Ultrasound Other: 3
4 17. What doctors have you seen, when were you seen, and what were you told about your pain? What were you told could be done to help you? 18. If you have had any of the following tests, please note where the test was done and the approximate date of the test. X-Rays Date: Location: CAT Scan Date: Location: EMG/NCV Date: Location: MRI Date: Location: Myelogram Date: Location: Discogram Date: Location: Other: PAST MEDICAL HISTORY 19. Please circle and explain if you have had a disease involving the following: Heart Problem Angina Stroke Asthma High Blood Pressure Tuberculosis Emphysema Coughing Breathing Problems Gallbladder Liver Problems Ulcers Colon Problems Blood in Stool Diarrhea Diarrhea Kidney Stones Kidney Problems Painful Urination Venereal Disease Arthritis Joint Problems Thyroid Problems Diabetes Osteoporosis Heavy Bleeding Hemophilia Anemia Scarlet Fever Cancer (any type) Epilepsy Seizures Depression Emotional Problems Fatigue Psoriasis Infection Other: 20. Have you ever been under the care of a psychiatrist or psychologist? If yes, for what diagnosis were you treated? 21. List all previous surgeries (other than the back/neck surgeries): 4
5 MEDICATIONS 22. What medications (with dosages) are you currently taking? PLEASE PUT A CHECK NEXT TO THE MEDICATION THAT WERE GIVEN TO RELIEVE THIS PROBLEM 23. Please list any allergies to any medication. ALLERGIES SOCIAL AND VOCATIONAL HISTORY 24. Are you a cigarette smoker? (check one) Yes No If you answered YES, how much do you smoke per day for and how long have you been smoking? 25. Do you drink alcoholic beverages? (check one) Never Only on rare occasions 1 to 2 per week 1 to 2 per day More than 5 drinks per day 26. Have you ever used drugs intravenously? Yes No 27. Please check your employment status Unemployed Employed Student Retired Homemaker Other: 28. Please check the type of occupation below that applies to the majority of your work habits Heavy labor Light labor Professional Student Unemployed Sedentary (Sitting or very little physical activity) 29. Please check the predominant activity of your work habits. Lifting Standing Twisting Driving Sitting Anything else: 5
6 30. Are you presently working? Yes No If not, is it because of this problem? Yes No What was the last date that you worked? Which physician recommended that you not work? 31. Please check the level of education you have completed. Grade school High school Some college College grad 32. Please check our marital status. Single Married Divorced Separated Widowed 33. Number of children, if any: REVIEW OF SYSTEMS 34. Please check any of the following problems which you have had within the past six months: Night Pain Weight Loss Appetite Change Marked Fatigue Night Fever Night Sweats Difficulty Sleeping Psychological Difficulties Uncontrolled Loss of Stool Blood in Stool Constipation Back or leg pain with Bowel Movement Difficulty with Urination Loss of Bladder Control Impotence/Reduced Sexual Function Joint Pain Joint Stiffness Joint Redness Joint Swelling 35. Is there any thing else that you wish to say or that we should know? Please complete the Pain Diagram as instructed. This is the last page. We thank you for your cooperation and assistance. 6
7 PAIN DIAGRAM Please mark the areas on your body where you feel the described sensations. Please include all affected areas and use the appropriate symbols as below: ACHE ^ ^ ^ ^ NUMBNESS 0000 PINS & NEEDLES = = = = = BURNING X X X X STABBING / / / / Please rate your pain on a scale of 1 through 10; 0=no pain; 10=intolerable Pain at its best: Pain at its worst: 7
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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
North Carolina Orthopaedic Clinic Patient Registration Form
North Carolina Orthopaedic Clinic Patient Registration Form FOR US TO PROCESS YOUR CHART, PLEASE COMPLETE FULLY AND PRINT CLEARLY PATIENT INFORMATION NAME: BIRTHDATE: AGE: TODAY S DATE: SOCIAL SECURITY
PATIENT REGISTRATION FORM
GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:
CONSULTATION & CONSENT FORMS p. 1 of 5 C J HERBAL REMEDIES, INC. ********************************************************************************
CONSULTATION & CONSENT FORMS p. 1 of 5 ******************************************************************************** List your full name, age, sex, and today's date List your complete address List your
Insurance (Let us make a copy of your insurance card and you can skip this section)
Today s Date: Name: What do you prefer to be called: Male / Female (please circle) Birth Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Email: Referred By: Employer: How long employed:
PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:
PATIENT INFORMATION SHEET PATIENT Last Name: First Name: MI: Gender: M F Date of Birth: / / SS# Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: Employer Name: Work Phone #: Email
(Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Today s Date:
Page 1 of 5 (Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Age: What is the main reason for today s visit? Today s Date: Who referred you to
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
Motor Vehicle Accident Information
Motor Vehicle Accident Information Last Name: First Name: Social Security no.: DOB: Your Auto Insurance Company: Policy #: Policy Holder s Name: DOB: Accident Claim #: Adjuster s Name: Phone #: Ext. Attorney
General Internal Medicine Clinic New Patient Questionnaire
General Internal Medicine Clinic New Patient Questionnaire Date: Name: What would you like to be called by the doctor? Marital Status: Please list how you would like to be contacted, for test results:
Grey Physical Therapy and Sports Medicine Center
Grey Physical Therapy and Sports Medicine Center 101 Phoenix Ave, 2D Body Made Better by Grey A Tradition of Caring Since 1984 Enfield, CT 06082 Ph (860) 741-2541 F (860) 745-5264 Patient Information First
Pulmonary Associates of Richmond
Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment
Lanier Chiropractic and Rehabilitation Information 4530 Nelson Brogdon Blvd., Suite B, Sugar Hill, GA 30024 770-271-8949
Lanier Chiropractic and Rehabilitation Information 4530 Nelson Brogdon Blvd., Suite B, Sugar Hill, GA 30024 770-271-8949 Thank you for choosing Lanier Chiropractic and Rehabilitation! It is our desire
CAMARILLO AQUATICS AND REHABILITATION SERVICES
CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did
CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident.
VANCE CHIROPRACTIC PERSONAL INJURY QUESTIONAIRE (PLEASE BE VERY SPECIFIC WITH YOUR ANSWERS THANK YOU!) Last Name First Name Middle Home Phone Work Phone Street Address and Number Mailing Address if Different
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