PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
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1 PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER TO CONTACT YOU: (CIRCLE ONE) CELL, HOME, OR OTHER. ENTER NUMBER BELOW. WORK ADDRESS / CITY / STATE / ZIP CODE OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. PERMISSION TO CONTACT YOU AT WORK IF NEEDED YES NO WORK PHONE NUMBER SOCIAL SECURITY NUMBER - - EMPLOYER OCCUPATION: EMERGENCY CONTACT AND RELATIONSHIP TO YOU EMERGENCY CONTACT NUMBER INSURANCE POLICY NUMBER GROUP NUMBER IF PERSON OTHER THAN YOU CARRIES THE INSURANCE ENTER THAT PERSON S NAME BELOW ENTER THE DATE OF BIRTH OF THE PERSON THAT CARRIES THE INSURANCE ENTER THE SOCIAL SECURITY NUMBER OF THE PERSON THAT CARRIES THE INSURANCE SECONDARY INSURANCE POLICY NUMBER GROUP NUMBER IF PERSON OTHER THAN YOU CARRIES THE SECONDARY INSURANCE ENTER THAT PERSON S NAME BELOW ENTER THE DATE OF BIRTH OF THE PERSON THAT CARRIES THE SECONDARY INSURANCE ENTER THE SOCIAL SECURITY NUMBER OF THE PERSON THAT CARRIES THE SECONDARY INSURANCE *PAINHP* PAINHP OVER Page 1
2 PAIN HISTORY FORM NAME: HT: WT: FAMILY DOCTOR: REFERRING DOCTOR: LOCATION OF PAIN: DESCRIPTION OF PAIN: ACHING NUMBNESS STINGING (Circle all that apply) BURNING PRESSURE TENDER CRAMPING SHARP TINGLING DULL SHOOTING THROBBING HEAVINESS STABBING TWISTING OTHER: CURRENT PROBLEM IS RESULT OF: CAR ACCIDENT WORK ACCIDENT FALL OTHER: DATE OF ACCIDENT DO YOU HAVE AN ATTORNEY? NO YES DATE OF ONSET OF PAIN: PAIN RATING (0 10 SCALE) ON A: GOOD DAY BAD DAY IS PAIN ALWAYS THE SAME? NO YES FREQUENCY OF PAIN: CONSTANT INTERMITTENT RARE DOES THE PAIN CAUSE (check all that apply): WEAKNESS FATIGUE IRRITABILITY ANXIETY DEPRESSION WHAT ACTIVITIES/FACTORS MAKE YOUR PAIN WORSE? (Ex: Sitting, Standing, Walking, etc) WHAT ACTIVITIES/FACTORS MAKE YOUR PAIN BETTER? (Ex: Heat, Ice, Rest, Medication, etc) HAVE YOU BEEN TREATED BY A PAIN MANAGEMENT SPECIALIST? NO YES WHO: WHERE: NAME ALL DOCTORS OR CHIROPRACTORS WHO HAVE TREATED YOU FOR PAIN: Page 2
3 PAIN HISTORY (CONTINUED) HAVE YOU HAD ANY OF THE FOLLOWING TREATMENTS FOR YOUR PAIN? NERVE BLOCKS/INJECTONS: WHEN WHERE EPIDURALS: WHEN WHERE PHYSICAL THERAPY: WHEN WHERE NARCOTICS: PLEASE LIST OTHER MEDICATIONS: PLEASE LIST TENS UNIT ACCUPUNCTURE BIOFEEDBACK HYPNOSIS SURGERY: WHEN: WHERE: PAIN PUMP: NO YES TYPE: SPINAL CORD STIMULATOR: NO YES TYPE: Have you had any of the following studies? X RAY: WHEN: WHERE: MRI: WHEN: WHERE: CT SCAN: WHEN: WHERE: MYELOGRAM: WHEN: WHERE: EMG: WHEN: WHERE: OTHER: OVER Page3
4 FAMILY HISTORY Please fill in the circle completely if you have a family member with the following. Unknown/Adopted Condition Father Mother Brother Sister Son Daughter Other Arthritis Asthma Bleeding Problems Cancer Type COPD/Lung Disease Diabetes Fibromyalgia Heart Disease Hepatitis High Blood Pressure HIV/AIDS Kidney Disease Liver Disease Migraines Psychiatric Illness Sickle Cell Stroke Thyroid Disease Tuberculosis Ulcers Other SOCIAL HISTORY MARITAL STATUS: NUMBER OF CHILDREN: DO YOU LIVE ALONE? NO YES OCCUPATION: SCHOOL LEVEL: GRADE SCHOOL HIGH SCHOOL COLLEGE GRADUATE SCHOOL CURRENT SMOKER? NO YES PACKS PER DAY YEAR STARTED DOES ANYONE OTHER THAN YOU SMOKE IN YOUR HOME? NO YES SMOKELESS TOBACCO: NO YES CANS PER DAY YEAR STARTED DRINK ALCOHOL? NO YES TYPE: AMOUNT: RECREATIONAL DRUG USE? NO YES LIST THE DRUGS YOU HAVE USED: HISTORY OF SUBSTANCE ABUSE: NO Y ES HISTORY OF REHAB FOR ALCOHOL OR SUBSTANCE ABUSE? NO YES WHEN DO YOU EXERCISE? NO YES HOW OFTEN TYPE OF EXERCISE: DISABLED? NO YES REASON FOR DISABILITY YEAR DISABLITIY BEGAN: Page 4
5 HEALTH HISTORY MEDICAL HISTORY: CIRCLE ALL THAT APPLY ARTHRITIS LIVER DISEASE HEART DISEASE ASTHMA KIDNEY DISEASE ULCERS CANCER (TYPE) MIGRAINES STROKE DIABETES BLEEDING PROBLEMS THYROID DISEASE COPD/LUNG DISEASE SICKLE CELL HIV/AIDS HEPATITIS TUBERCULOSIS FIBROMYALGIA HIGH BLOOD PRESSURE CHRONIC FATIGUE PSYCHIATRIC ILLNESS OTHER: SURGERY HISTORY: PLEASE LIST ALL PAST SURGERIES SURGERIES YEAR SURGEON COMPLICATIONS OVER Page 5
6 MEDICATIONS: LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING INCLUDING VITAMINS, HERBALS AND OVER THE COUNTER MEDICATIONS MEDICATION DOSAGE FREQUENCY REASON FOR TAKING MEDICATION ALLERGIES: NONE LATEX ALLERGY: NO YES Reaction: MEDICATION REACTION Page 6
7 HEALTH HISTORY (CONTINUED) Are you on blood thinning medication (i.e. aspirin, Plavix, Coumadin, Xarelto, etc) NO YES List: Date of last dose: Are you currently on: Steroids? NO YES Antibiotics? NO YES Chemotherapy? NO YES Have you ever had problems with sedation or general anesthesia? No Yes Explain: Do you have a family history of problems with anesthesia? Explain: NO YES Have you had any recent: Surgeries Procedures Major dental work Do you have: Pacemaker Metallic Fragment Foreign body (Check all that apply) Aneursym clip or coil Last Menstrual Period Are you pregnant? No Yes Are you lactating? No Yes OVER Page 7
8 REVIEW OF SYSTEMS Please mark ALL THAT APPLY TO YOU GENERAL: GASTROINTESTINAL: PSYCHIATRIC: Fever Nausea or vomiting Depression Chills Diarrhea Anxiety Sweats Constipation Memory loss Loss of appetite Change in bowel habits Confusion Fatigue/weakness Bowel incontinence Suicidal Weight loss Blood in stool Bipolar disorder Problems sleeping Stomach ulcers ENDOCRINE: EYES: Indigestion/heartburn Cold intolerance Wears glasses or contacts Hepatitis: jaundice Heat intolerance Blurred vision Swallowing problems Diabetes Double vision GENITOURINARY: Excessive thirst Eye pain Vaginal discharge/bleeding Thyroid disease Sensitive to light Incontinent of urine HEMATOLOGICAL: Glaucoma Blood in urine Bruise easily EARS/NOSE/THROAT: Frequent urination Bleed easily Earache Kidney stones Anemia Ear Discharge Pelvic pain Blood clots Ringing in ears Irregular menstrual periods ALLERGY/IMMUNE: Decreased hearing MUSCULOSKELETAL: Hives or rash Nasal Congestion Back pain Seasonal allergies Sore throat Joint pain HIV exposure Hoarseness Joint swelling Persistent CARDIOVASCULAR: Muscle cramps infections Chest pains Muscle weakness Palpitations Stiffness OTHER HEALTH ISSUES: Fainting Arthritis Shortness of breath Restless legs Swelling of hands or feet Leg pain at night Heart attack SKIN: High blood pressure Rash Pacemaker Itching/dryness RESPIRATORY: Change in hair Frequent cough Change in skin color Coughing up blood Change in nails Shortness of breath Suspicious lesions Wheezing Neurological: Stroke Asthma Paralysis Head Injury Tuberculosis Numbness/tingling sensations Vertigo/Dizziness COPD/Emphysema Convulsions or Seizures Frequent headaches Frequent falls PLEASE SIGN: DATE: *PAINHP* Page 8 PAINHP
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PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL
Personal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
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
RETINA CARE CENTER, P.C. PATIENT INFORMATION
RETINA CARE CENTER, P.C. JONATHAN M. BAROFSKY, M.D., F.A.C.S. Parkway Seventy Plaza 1255 Route 70, Suite 31N Lakewood, New Jersey 08701 PHONE (732)905 0004 FAX (732)905 3868 PATIENT INFORMATION Welcome
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:
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient Name: Date: Address: City: State: Zip Code Best Phone Number: Marital Status Phone (H): (W) (Cell):
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
Name: Date: Address: City: State: Zip: Phone (Home): ( ) Work: ( ) Address: Address:
1 Geoffrey Tyson, M.D. 6808 220 th Street S.W., Suite 201, Mountlake Terrace, Washington 98043 Phone 425-640-6976 Fax 425-640-6977 Health History and Pain Questionnaire THIS FORM MUST BE RETURNED 10 DAYS
Patient Intake Form. Patient Information. How did you find out about our office?
Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our
Patient Information. Today s date: Your Name: Social Security Number: Date of Birth: Age: Height: Weight: lbs. Street Address: City/State/Zip:
Welcome to Avenstar Pain Specialists! Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
Name (First): (MI) (Last) Date: Address: City: State: Zip: Home Phone: Cell Phone: E-mail: Driver s License #: Driver s License State: Occupation:
Board Certified Please Print: Name (First): (MI) (Last) Date: Address: City: State: Zip: Home Phone: Cell Phone: E-mail: Driver s License #: Driver s License State: Occupation: DOB: Age: Sex: SSN#: Employer:
Rehabilitation Medicine Clinic. New Patient Questionnaire
Rehabilitation Medicine Clinic (Please complete this 5-page form and bring to your appointment.) Date Appt. Date Age Date of Birth Name Male Female Hand dominance: R L Home Address Home Phone ( ) Work
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,
Health Information Form for Adults
A. Identification B. Emergency Contacts Name (Last) (First) (Middle) Maiden Name In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Primary Alternate Relationship Home Work Home
IF THIS IS RELATED TO A WORKMAN S COMPENSATION CLAIM OR AN AUTOMOBILE ACCIDENT, PLEASE FILL OUT ADDITIONAL SHEET IN THE BACK OF THIS PACKET (PIP FORM)
PATIENT INFORMATION Last Name: First: MI: of Birth: Social Security #: - - Address: City State Zip Home#: ( ) - Cell#: ( ) - Employer: Employer#: ( ) - Occupation: Retired Unemployed Student Self-Employed
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
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)
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.