NEW PATIENT INFORMATION FORM
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1 Woosik M. Chung, M.D. Timothy R. Kuklo, M.D., J.D DISC (3472) NEW PATIENT INFORMATION FORM Please print all information. By fully completing this form, you allow us to serve you quickly and efficiently. If you already have completed this form in the last 3 months, please fill out just the first 2 pages and any items on the remaining pages that have changed since your last visit. Date of Visit: Date of Birth: Age: Patient Name: Male Female Address: Phone: Cell: ( ) Home: ( ) Work: ( ) Referrals: How were you referred to The Denver International Spine Center: Physician Patient /Friend Internet Workers Comp Insurance Radio /TV Emergency Room: Other: Referring Physician or Referral Source: Address: City: Phone: ( ) Fax: ( ) Do you want your medical records sent to this physician? Yes No Physicians: Primary Doctor: Address: City: Phone: ( ) Fax: ( ) Do you want your medical records sent to this physician? Yes No Other Physicians Would you like your medical records sent to any other physicians? (Please include name and address) (Continued on next page)
2 SYMPTOM CHART Mark the areas on your body where you feel the described sensations using the appropriate symbol from the list below. Please include all affected areas. = = = Numbness = = = = = = = Pins & Needles= o o o o o o o o o Burning/Aching = x x x x x x x x x / / / / Stabbing = / / / / / / / / Please indicate your current pain level by placing a line below with 0 = no pain and 10 = worst pain imaginable. Example: Pain 0 10 Pain on Average 0 10 Pain at its Worst 0 10 Pain at its Best (lying down, resting) 0 10
3 CURRENT SYMPTOMS 1. Where is your problem located? Neck Upper Back Arm Mid Back Lower Back Hip Leg 2. How long have you had this problem? Since? / / 3. Briefly, please give the details of how this problem originally started: 4. Was this from a work-related injury? No Yes - Is it under workers compensation? No Yes Have you missed any work because of this problem? No Yes, how much? 5. Please describe your present pain/problem now (what you feel, where, when, etc.): 6. Have you had spinal surgery in the past: (Check one) No Yes - How many times? What type of surgery(s) was/were performed? Discectomy Laminectomy Fusion IDET Unknown Other: What spinal level? What was the date of your most recent spine surgery? Did you improve from your spine surgery procedure(s)? Yes No 7. Which of the following best describes your ratio for neck & arm or back & leg discomfort (if appropriate) Back Neck A. 100% back pain and 0% leg pain A. 100% neck pain and 0% arm pain B. 75% back pain and 25% leg pain B. 75% neck pain and 25% arm pain C. 50% back pain and 50% leg pain C. 50% neck pain and 50% arm pain D. 25% back pain and 75% leg pain D. 25% neck pain and 75% arm pain E. 0% back pain and 100% leg pain E. 0% neck pain and 100% arm pain 9. For any pain/numbness in your arm(s) or leg(s), which side is worse? (Choose one if appropriate) Leg Symptoms Arm Symptoms A. 100% left leg and 0% right leg A. 100% left arm and 0% right arm B. 75% left leg and 25% right leg B. 75% left arm and 25% right arm C. 50% left leg and 50% right leg C. 50% left arm and 50% right arm
4 D. 75% right leg and 25% left leg D. 75% right arm and 25% left arm E. 100% right leg and 0% left leg E. 100% right arm and 0% left arm (Continued on next page) CURRENT PAIN PROFILE 10. Please choose letters A F (in first column) to answer the questions in column two. A. Unable to tolerate How long can you sit? B. About 15 minutes only C. About 30 minutes only How long can you stand? D. About 45 minutes E. About 1 hour How long can you walk? F. Indefinitely 11. Which of the following activities change the nature of your pain? Aggravates Relieves Neither Pain Pain Sitting Standing Walking Leaning forward (brushing teeth) Bending forward Lying on your side Lying on your back Lying on your stomach Rising from sitting Changing positions Coughing/Sneezing Driving Now go back and CIRCLE the box to indicate the most aggravating activity and the most relieving activity. 12. If the symptoms of your present pain have changed, please indicate the most appropriate statement: (Circle one) A. My symptoms have remained the same since the time of onset. B. My symptoms are more severe since the time of onset C. My symptoms are less severe since the time of onset. 13. How have the symptoms of your present pain changed: (Circle one)
5 A. no change in symptoms B. increased aggravation in one arm or leg C. increased aggravation in both arms or legs D. increased aggravation in the back or neck E. increased aggravation in both arms/legs and back/neck (Continued on next page) PAST SPINE HISTORY 14. Of the following list of treatments, please indicate the effect of those which have been used in an attempt to help your present injury: (Check one of each) Which Type Helpful No Help Not Used Anti-inflammatory Muscle Relaxants Narcotic Pain Medications Hot Packs Ice Ultrasound TENS Unit / Muscle Stim (Circle) Physical Therapy Treatment Back/Neck Exercises Chiropractor Epidural Block/Injection Facet Block/Injection SI Joint Block/Injection Trigger Point Injection Acupuncture Traction / VAX-D (Circle) Other: 15. Please indicate whether you have had any of the following studies and write when/where the most recent was: Regular X- ray of Spine CT Scan of Spine Yes No When/Where Yes No When/Where Myelogram Discogram EMG MRI of spine Bone Scan 16. Have you had any past episodes of similar pain or injury? Yes (please describe) No
6 17. List all other physicians with whom you have consulted in the past year for this problem. (Continued on next page) MEDICAL HISTORY Please choose all current and past medical conditions No medical problem High blood pressure Heart attack Abnormal heart rhythm Lung disease Tuberculosis Asthma Bronchitis Emphysema Liver disease Hepatitis Multiple Bone Factures Diabetes Thyroid disease Stomach ulcers Irritable bowel Stroke Seizers Cancer where? Kidney failure Kidney stones Osteoporosis Osteoarthritis Rheumatoid arthritis Are you under a doctor s care for any other medical condition? Yes No If yes, please explain Bleeding disorders Anemia Blood clots in legs/lung Endometriosis Ovarian cysts Anxiety Depression Schizophrenia Anorexia/bulimia Alcoholism Seen a psychiatrist HIV Please choose all surgeries you have had: SURGICAL HISTORY Spine-Neck Spine-Lower back Brain Heart Angioplasty/ Stent Lung Gallbladder/ Stomach Appendix / Intestine Hernia/ Colon / Rectum Hysterectomy / C-section/ Female Kidneys / Bladder / Urinary Prostate Shoulders / Arms/ Hands Hips/ Knees/ Legs / Feet Eyes Ears Throat / Tonsils Other: Current Medications Name Dose Allergies Substance
7 Reaction
8 SOCIAL HISTORY 18. Current work status: Working full duty Working restricted duty (Since ) Retired Disabled (Since ) Student Homemaker Unemployed Company: Occupation: Title: How long have you worked for this company? 19. Marital status: Single Married Divorced Widowed 20. Number of children: 21. I live: Alone With: 22. I live in a: House Apartment Assisted living Nursing home 23. Are you a cigarette smoker? Yes, now Never Quit - How long ago did you quit? If you answered yes or quit, how much do or did you smoke per day? Less than ½ pack ½ pack ¾ pack 1 pack More (How many? ) How old were you when you started smoking? 24. Are you a marijuana user? Yes, now Never Quit - How long ago did you quit? If you answered yes or quit, how much do or did you use per day? 25. Do you drink any alcoholic beverages? (Check one) None 0 to 3 drinks per month 1 to 2 drinks per week 1 to 2 drinks per day 3 to 5 drinks per day More than 5 drinks per day. How many? Alcoholic in past? Yes No 25. Have you ever had a problem with drug dependence? Yes No 26. Are there any law suits pending or contemplated related to your problem? Yes No If yes, please give your attorney s name and phone number: 27. Please write any additional information that you feel is important for us to know. (Continued on next page)
9 FAMILY HISTORY What illnesses run in your close family? Scoliosis Spine disease Arthritis Heart disease High blood pressure Diabetes Cancer Bleeding disorder Mental illness Alcoholism Kidney disease Other: REVIEW OF SYSTEMS Please check off any current or recent problems you have GENERAL Unexplained weight loss Appetite change Fevers or chills Night sweats Marked fatigue Difficulty sleeping EAR, NOSE, THROAT Difficulty swallowing Hoarseness Loss of hearing Ear pain Nosebleeds Gum trouble EYES Glasses Change of vision CARDIOVASCULAR Heart or chest pain Abnormal heartbeat Poor heart function LUNG Morning cough Fevers or chills Night sweats Marked fatigue Shortness of breath Productive cough or sputum DIGESTIVE Nausea or vomiting Stomach pain or ulcers Heartburn/acid stomach Frequent diarrhea Frequent constipation Uncontrolled loss of stool Blood in stool Hemorrhoids SKIN Frequent rashes Frequent itchiness Easy bruising Swollen ankles NEUROLOGICAL Seizures Blackouts/fainting Tremor Difficulty sleeping Headaches/migraines MUSCLOSKELETAL Joint Pains/Swelling Back Pain Neck Pain Muscle Aches GENITOURINARY Burning on urination Difficulty starting urination Incontinence Pelvic pain Urinate at night more than once Unable to completely empty bladder PSYCHIATRIC Depression Nervous exhaustion Anxiety Paranoia Obsessive/compulsive behavior
10 Woosik M. Chung, M.D. Timothy R. Kuklo, M.D., J.D DISC (3472)
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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
NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone Email address
NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
Consultants in Pain Medicine, P.A.
Consultants in Pain Medicine, P.A. ASSIGNMENT OF BENEFITS Private insurance authorization for assignment of benefits and information release: I, the undersigned, authorize payment of medical benefits to
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:
Orthopedic Patient Information
Orthopedic Patient Information Please complete the following questionnaire. It is designed to assist our providers with your care and better understand your medical information. Please answer every section.
317 N. EI Camino Real, Suite 405 Encinitas, CA 92024 (760) 994-2663. Dear Patient:
317 N. EI Camino Real, Suite 405 Encinitas, CA 92024 (760) 994-2663 Dear Patient: We are very happy to welcome you to Orthopedic Surgery San Diego. We appreciate the opportunity to take care of you and
412 Holistic Health, LLC Maura Schuster, L.OM 412.841.2065 Practitioner of Oriental Medicine NEW PATIENT INTAKE
412 Holistic Health, LLC Maura Schuster, L.OM 412.841.2065 Practitioner of Oriental Medicine NEW PATIENT INTAKE PATIENT INFORMATION Date Name Address City State Zip Age Birthdate Occupation Company name
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM (Please Print) Name: LAST FIRST Ml Street Address: STREET APT CITY STATE ZIP Home Phone #: ( ) ) Cell Phone #: ( ) ) Social Security #: Birth date: Age: Sex: M ; F Marital Status:
Name: Date of Birth: Age: Male / Female (circle one) Pregnant Yes / No (circle one) Reason you are here:
Eastside Medical Group: DATE: Name: Date of Birth: _Age: Male / Female (circle one) Pregnant Yes / No (circle one) Reason you are here: SOCIAL HISTORY Marital Status: Single Married Partner Divorced Widow/Widower
PATIENT NAME: AGE: ACCOUNT NO.: Ache XXXXXX 0% 100%
AGE: DATE OF VISIT: TIMEPOINT: Mark these drawings according to where you hurt. If the back of your neck hurts, mark the drawing on the back of the neck, etc.) If you feel any of the following symptoms,
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION State: Zip Code: Preferred Pharmacy: Phone: Home Work Other Referring Physician: Phone: Home Work Other Primary Care Physician: E-Mail Address: EMERGENCY CONTACT
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
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
Motor Vehicle Accident - New Patient
Motor Vehicle Accident - New Patient Today's Date: Patient Name: Auto Insurance Company of Car You Were In: Phone: Insurance Agent: Phone Was A Police Report Made? Have You Informed Your Agent of 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:
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:
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
Work Injury Information Continued
Welcomes You Full Name: Today s Date: DOB: M / F Social Security #: DL# Address: City: State: Zip Code: Home # : Cell #: Occupation: Employer: Employer Address: Employer Phone: Employer Fax: Emergency
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:
How To Fill Out A Health Declaration
The English translation has no legal force and is provided to the customer for convenience only. The Dutch health declaration should be filled in. Health declaration for occupational disability insurance
Orthopaedic Institute of Ohio Demographic Information Date:
Orthopaedic Institute of Ohio Demographic Information Date: Patient Name Home Phone Cell Phone Employer Phone Mailing Address (include PO Box and Apt. #) Family Doctor Name and Phone Number City, State,
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration
PATIENT PAIN DRAWING. Name: DOB: Chart: Date: Name Date
PATIENT PAIN DRAWING Name Date Where is your pain now? Mark the areas on your body where you feel the sensations described below, using the appropriate symbol. Include all affected areas and please draw
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: First Middle Initial Last DOB: / / Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - Email: (for patient portal purposes only)