Interventional Spine Care New Patient History and Intake Form
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- Sydney Howard
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1 Interventional Spine Care New Patient Introduction You have been referred to Dr. Hamburger/Dr. Olson. Our focus is the evaluation and management of low back pain, and other disorders of the spine. Our goal is to help you improve your level of function, assist with the management of your symptoms and hopefully reduce your level of pain. In order to develop an effective treatment plan, we need to obtain very detailed information about you and your health. Please take the time to complete the following questionnaire in its entirety, as this will assist us in your evaluation. Should any aspect of the questionnaire remain empty, we will ask that you complete the questionnaire prior to being seen by the physician which may lead to a delay in your visit. If you have any trouble filling out the form, please advise our staff so that we may assist you. Center Policies: 1. Please call us at least 48 hours in advance if you are unable to keep your scheduled appointments. We do NOT currently charge for missed appointments. 2. Patients who miss scheduled appointments without adequate prior notification may be dismissed from the practice at the discretion of the physician. 3. Please make every effort to arrive on time for appointments. Late-arriving patients may have to be re-scheduled. 4. On your first visit please bring along a COMPLETE list of your medications so that we may correctly keep track of them. 5. On your first visit please bring along Hard Copies (either Films or CDs) of your recent (preferably last 2 years) MRIs, CT scans, X-rays as it relates to your pain condition. Chronic Pain: 1. Please understand chronic pain is different from acute pain. There is rarely immediate relief from chronic pain. It may require several treatments/visits to begin to determine the correct underlying diagnosis, as well as address the chronic pain and its related issues. 2. Dr. Hamburger and Dr. Olson employ a non-narcotic approach to chronic pain, and as consultants we do not take over the prescription of chronic pain medication, but will make recommendations to the referring physician. Outpatient Clinic: - As this is an outpatient clinic, we do not provide emergency care. Any medical emergencies need to be addressed through an Emergency Room (E.R.) visit. Thank you, Adrian Hamburger, M.D. & Timothy Olson, M.D., PhD.
2 Interventional Spine Care New Patient History and Intake Form Date: Name: Date of Birth: Sex (M/F): 1) Who referred you? Primary Care: Referring Specialist:
3 3. How did the pain start? Rate your pain by circling the number that Suddenly Pulling describes your pain at its WORST (0=No Pain) Gradually Injured at work Lifting Injured in auto accident Twisting Hit from behind Rate your pain by circling the number that Fall Injured during sports describes your pain at its LEAST (0=No Pain) Bending No apparent cause 4. What activities make the pain worse? Exercise (during) Bending forward Rate your pain by circling the number that Exercise (after) Bending backward describes your pain on the AVERAGE Sitting Coughing Standing Sneezing Walking Twisting 1 - Easy to ignore, 2 - Tolerable, 3 - Distracting 4 - Distressing and Interferes with activities 5. What reduces the pain? 5 - Very Distressing/prevents some activities Lying down Physical Therapy 6 - Very Distressing/Trouble with simple activities Sitting Injections 7 - Need Help from others for simple activities Standing Muscle Relaxant Pills 8 - Pain prevents movement, 9 - Screaming/Agony Walking Anti-inflammatory Pills 10 - Passing out due to pain Chiropractic Cognitive Therapy 12. Allergies: TENS unit Other: Contrast dye (or Iodine) Antibiotic(s): 6. Have you had any of these? Other: Yes No Diagnostic X-rays 13. Medications: CT scan Please list your current Pain Medications: Myelogram EMG Discogram MRI Please list your current Regular Medications: Injections 7. Have you had any of these symptoms? numbness (where: ) weakness (where: ) loss of bladder control Plavix Coumadin Ticlid loss of bowel control Any other blood-thinner If female: pregnant/breast-feeding? Yes No 8. Have you ever been hospitalized or seen in the ER for this pain? No Yes - Number of times Most recent visit (Date) 9. Have you had surgery for this problem? No Yes - What kind of surgery (ie: fusion, discectomy): Major Illness or Medical Problems: Diabetes High Blood Pressure Heart Disease Asthma Emphysema Hepatitis High Cholesterol Glaucoma Heart Attack (When: ) Seizures Other Medical Problems: Past Surgeries (please include dates):
4 Family History (please list any major health problems) Mother s age: ( deceased) Father s age: ( deceased) Siblings: Children: Social History: Single Married Separated/Divorced Widowed Name of Employer: Retired Unemployed Disability If you had an injury, was it work related? Yes No Disability: Yes No Since: (please indicate Year of disability) Litigation: Are you currently involved or planning on initiating a legal case? Yes No Tobacco: Yes-Currently Yes-in the past No-never How many packs/day? How many years did you smoke for? When did you quit? Alcohol: Yes No If yes, how many drinks/day? Illicit Drug Abuse: Marijuana Heroin Cocaine Amphetamines None Have you ever had a problem w/ prescription medications (ie: misuse, abuse, addiction)? Yes No Which drugs? History of Alcohol Abuse: Yes No History of Substance Abuse: Yes No Review of Symptoms (please check the box if you have had any of these symptoms recently): Constitutional: Fatigue Unexpected Weight loss Unexpected Weight gain Fever Chills Pulmonary/Respiratory: Shortness of breath Cough Blood Wheezing Cardiac/Heart: Chest Pain Palpitations Arrhythmia Leg swelling Valve disease Gastro-intestinal: Loss of appetite Difficulty Swallowing Nausea Constipation Hemorrhoids Blood in stool Ulcers Diarrhea Genito-Urinary: Frequent urination Difficulty urinating Painful intercourse Menstrual problems Pain during urination Kidney Stones Blood in urine Prostate problems Hematologic Tender lymph nodes Anemia Bleeding gums Bleeding disorder Musculoskeletal: Joint Pain Muscle Cramps Fractures Difficulty walking (requiring cane/walker) Skin: Dry Skin Itching Rash Jaundice Neurological: Headaches Seizures Paralysis Dizziness Vertigo Psychological/Psychiatric: Depression Anxiety Sleep disorder Suicide attempts Suicidal thoughts Mood swings Confusion Memory Loss Endocrine: Goiter Diabetes Hair loss Poor Tolerance of Heat or Cold
5 Location and Directions Westerly Office is located on the 2nd floor of the Morgan Building. 45 Wells Street Suite 201 Westerly, RI Tel (401) Fax (401) From Rhode Island Take I-95 South to exit 1. Bear right onto Route 3and follow to Route 78. Take 78 East to Route 1 and turn right. Follow to the third traffic light; turn left onto Wells Street. From Connecticut Take I-95 North to exit 92. Bear right onto Route 2. Follow to Route 78 East. Take 78 East to Route 1 and turn right. Follow to the third traffic light; turn left onto Wells Street. Wakefield Office is located in the South County Internal Medicine/XRA building: 481 Kingstown Road Wakefield, RI Tel (401) Fax (401)
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341 Magnolia Avenue, Suite 101 28078 Baxter Road, Suite 330 Corona, CA 92879 Murrieta, CA 92563 (951) 735-6060 (951) 735-4510 Fax (951) 677-2157 www.ctoamg.com WORKER S COMPENSATION HISTORY FORM NAME (Last,
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:
Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC 27103 PH. 336-768-3530 FAX- 768-1329. Scott W. Baker, MD. Patient Instructions
18 HEALY DR. WINSTON SALEM, NC 710 PH. 6-768-50 FAX- 768-19 Scott W. Baker, MD Patient Instructions 1. Bring a list of all regular medications and dosages.. Bring your insurance card and all necessary
o Enclosures 4-5: Organizational Policies and Financial Policy The enclosures are informational only, no action is necessary.
Dear Patient: Welcome and thank you for choosing InterMed Sports Medicine. We are honored that you have entrusted your care with us. InterMed prides itself on providing the highest quality health care
Liver Disease & Hepatitis Program Providers: Brian McMahon, MD, Steve Livingston, MD, Lisa Townshend, ANP. Primary Care Provider:
Liver Disease & Hepatitis Program Providers: Brian McMahon, MD, Steve Livingston, MD, Lisa Townshend, ANP Primary Care Provider: If you are considering hepatitis C treatment, please read this treatment
Recognition for superior care
On behalf of the Spine Center team, we would like to welcome you. At the Spine Center we strive to give our patients exceptional, state-of-the-art care. Although we have received the national recognition
PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date:
WORKERS COMPENSATION HISTORY PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date: Address: City: State: Zip:
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
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
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,
Rheumatology Associates of North Jersey New Data Sheet
Personal History Rheumatology Associates of North Jersey New Data Sheet To our new patients: Welcome to our practice. SS: - - Date: Last Name: First Name Date of Birth / / Age Address City State Zip Code
NORTHERN EDGE PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST In order to make registration simple and quick, please use this checklist to make sure you have provided all necessary information and signatures. The process, including
Diuretics: You may get diuretic medicine to help decrease swelling in your brain. This may help your brain get better blood flow.
Hemorrhagic Stroke GENERAL INFORMATION: What is a hemorrhagic stroke? A hemorrhagic stroke happens when a blood vessel in the brain bursts. This may happen if the blood vessel wall is weak, or sometimes
A photocopy of this document shall be considered as effective and valid as the original.
p In order for us to obtain a complete medical history, it is important for you to fill out this form in its entirety. Every item needs to be filled out. This information will be entered into our Electronic
WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
Neuropsychological Testing Appointment
Neuropsychological Testing Appointment Steven A. Rogers, PhD Kathleen D. Tingus, PhD 1701 Solar Drive, Suite 140 Oxnard, CA 93030 When will it be? Date: Time: Examiner: What will I have to do? Each appointment