New Patient Questionnaire
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- Nickolas Allen Franklin
- 8 years ago
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1 New Patient Questionnaire Name: Date: Age: Date of Birth: Right or Left Handed: Height: Weight Primary Care Doctor: Address and Phone number: Occupation (If working): Current work status (full duty, light duty, modified, etc.) List all medical illnesses: indicate with Y (yes) or N (no). Anemia Stomach Ulcers Leg Cramps Arthritis Excessive bleeding Phlebitis Asthma Heart Problems Rheumatic fever/murmur Birth Control Pills High blood pressure Liver Problems Circulation problems Hormone Therapy HIV or AIDS Diabetes Kidney Problems Thyroid problems Any others? List all previous surgeries, surgeon s name and approximate dates: List all current medications and doses: Allergies to medications or latex? Do you smoke? If so, how much? What is the main problem for which you are seeing us today?
2 New Patient Questionnaire When did you first begin to have this problem? Injury (or injuries) which you feel are related to the problem for which we are seeing you today? (Please indicate approximate dates) List names and dates of doctors you have seen for this problem: Treatments you have for this, (Medications, Therapies, Splints, etc.) dates: Have you had other treatments such as chiropractic, acupuncture, massage, etc.? Please list with dates: Was this a work related illness/injury or accident? Specific date of work illness/injury or accident? Was this illness/injury or accident the result of a motor vehicle accident? Specific date of motor vehicle accident? I certify that the information provided, here in, is true and correct to the best of my knowledge. Signature: Date:
3 PAIN QUESTIONAIRE Please mark the areas on the body diagram where you feel the described sensations: Ache ++++ Numbness Pain and Needles oooo Burning xxxx Stabbing ////
4 INSTRUCTIONS Rate your MAJOR AREA OF PAIN on the 0 10 Pain Rate Scale. Write the NUMBERS of your pain at the present time and your best day and worst day over the past 30 days. Remember, the number refer to your pain, not how strong or weak you feel. For example: Number 1 is a Minimal Pain and Number 7 is a Strong pain. 10 Excruciating; you need to call emergency services 9 Very, very strong pain 8 Very strong pain 7 Strong pain 6 Somewhat strong pain 5 Moderate pain 4 Somewhat moderate pain 3 Light pain 2 Very light pain 1 Minimal pain 0 No pain at all YOU RE PAIN RATE Pain Now OVER LAST 30 DAYS Best Day Worst Day
5 Welcome to Arapahoe Sports Medicine and Rehabilitation. We are glad that you are here and have entrusted us with your care. Everyone at Arapahoe Sports Medicine and Rehabilitation is committed to you and your health and together we will strive to get you back on the road to recover. What should I expect on my visit to Arapahoe Sports Medicine? On your first visit, we may ask you to fill out a brief new patient form which includes your basic demographic information: name, date of birth, telephone, emergency contact, medical history, and also information regarding insurance coverage or other billing issues. We will also provide you with a handout explaining our privacy practices. You will be evaluated by a physical/occupational therapist through physical testing and measurements, and by providing an oral history of the problem. You will also receive treatment by the therapist on your first visit. Please bring a photo I.D., your prescription for therapy, insurance card, and any anticipated copay monies. What should I wear to therapy? You should wear comfortable clothing, as you will be asked to lie on a mat and change positions occasionally for your treatment. We will usually require access to the skin of the affected area, so short sleeves or shorts are recommended for problems involving knees or elbow. How much time is involved? Your first visit should last 45 to 60 minutes; subsequent visits are approximately 30 to 60 minutes. Additional time may be required for an exercise program, either in our office or at home. If you are not able to attend scheduled or prescribed appointments please call to reschedule. Will you file my insurance? We will file your medical insurance or worker s compensation claim for you. We will also provide itemized statements to auto insurance companies, or to your attorney as requested by the patient. What should I expect to pay for therapy? Charges will vary depending upon your individual treatment plan. Typically charges for a visit will range from $70.00 to $ As a service to you, we will call your insurance company to verify your benefits for therapy and your ability to receive treatment at Arapahoe Sports Medicine and Rehabilitation. The information they provide will clarify your policy s coverage terms, limits, and your financial responsibility. We recommend that you obtain this information prior to your first appointment if you have any concerns about your coverage. Simply call the customer service number on your insurance card and ask for your coverage for additional physical therapy. Colorado Orthopedic Consultants, dba Arapahoe Sports Medicine and Rehabilitation Center 1411 S Potomac St, Suite W Hampden Ave., Suite 500
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New Patient Registration Form
New Patient Registration Form Welcome to Bayside Dental Care! We look forward to giving you the best dental experience possible. Please complete both sides of this form. Let us know if you need any assistance
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION Last Name First Name MI Mailing Address City Zip code Home Phone
NEW PATIENT REGISTRATION
Title Mr / Mrs / Ms / Miss / Master / Dr Surname Given Names Address Postcode. Date of Birth. Age Occupation Telephone H.. M. W.. Next of Kin:. Tel:.. Referring Dr. Address.. Private Insurance YES / NO
WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
H. Kevin Jones, MD Evan C. Reese, MD Becky Jones, ANP-BC
Dear New Patient: Welcome to our practice! We appreciate the opportunity to help you take care of your healthcare needs and look forward to a long and healthy relationship. Please complete the forms completely
Orthopedic Specialists Of SW FL New Patient Information Form
Orthopedic Specialists Of SW FL New Patient Information Form Patient Name: DOB Age M or F SS# Home Ph# Cell Ph# Work# Local Address City/State Zip Code Northern/Other Address City/State Zip Code Reason
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:
RALPH R. GARRAMONE, MD, FACS (239) 482-1900
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions