Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach



Similar documents
Horn Family Chiropractic Non-Surgical Spinal Decompression Application For Admission

Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE Schoenherr Road, Suite 230 Shelby Township, MI (586)

Dallas Neurosurgical and Spine Associates, P.A Patient Health History

Workman s Compensation

MEDICAL HISTORY AND SCREENING FORM

Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at

St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION

New Patient Intake Form

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:

PLEASE PRINT LEGIBLY

Patient Intake Form. Patient Information. How did you find out about our office?

General Internal Medicine Clinic New Patient Questionnaire

PATIENT INFORMATION INSURANCE INFORMATION

Name Last First Middle. (Complete Mailing) Address ** Street Apt# City State Zip. Work Phone # ( ) ** Emergency Contact Relationship Phone# ( )

JAMES PETROS, M.D., INC. PHONE: (408) FAX: (408)

New England Pain Management Consultants At New England Baptist Hospital

PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )

The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il Tel: Fax:

NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE

Height FT IN Weight Married? Y / N Employed? Y / N

Full name DOB Age Address Phone numbers (H) (W) (C) Emergency contact Phone

Southwestern Foot & Ankle Associates, P.C Parkwood Blvd, Suite 602 Frisco, TX Phone: Fax: Dr. Thomas H.

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico (575) Fax: (575)

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

Lighthouse IF YOU WERE THE DRIVER OF YOUR OWN VEHICLE, SOMEONE ELSE S VEHICLE OR A PASSENGER IN THE VEHICLE, ANSWER THIS SECTION COMPLETELY.

Name Home phone Work phone. Address. address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

412 Holistic Health, LLC Maura Schuster, L.OM Practitioner of Oriental Medicine NEW PATIENT INTAKE

Dear Patient, Sincerely, Gastroenterology Associates of North Jersey

PATIENT REGISTRATION FORM

Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX Phone-214) Fax-214)

PATIENT HISTORY FORM

Pulmonary Associates of Richmond

NEW PATIENT INFORMATION FORM

Plano Heart Center, P.A.

PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX Phone Fax PATIENT REGISTRATION

CLINIC APPLICATION. Client Information

PATIENT INITIAL FORM

NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE

CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD

Surgery Health Survey

Emory Eye Center New Patient Questionnaire

1584 Wesleyan Drive FORM A Norfolk, VA Phone: (757) Health History immunization & Physical Form

Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL Phone (727) FAX (727)

New Patient Registration Information

PATIENT REGISTRATION FORM

Insured Party Information (please complete if the insurance is not in your name)

FATHER Present Health MOTHER Present Health Spouse Present Health

THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History

How to Remove a Social History Smoke?

Patient Registration Form

317 N. EI Camino Real, Suite 405 Encinitas, CA (760) Dear Patient:

Women s Continence and Pelvic Health Center

DRX 9000 Registration Form

Patient Information Form Pain Management Center at Phoebe

*3451 BARIATRIC SERVICE HEALTH QUESTIONNAIRE

Notice of Privacy Practices

WORKERS COMPENSATION INFORMATION

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER

PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:

INITIAL PATIENT QUESTIONNAIRE-

Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:

Work Injury Information Continued

BRENTWOOD EAST FAMILY MEDICINE Patient Registration Form (ecw)

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)

Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:

CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) FAX (757) INTERNET **MEDICATION GUIDELINES PRIOR TO PROCEDURES

***************PATIENT INFORMATION****************

Personal Injury Questionnaire

Rehabilitation Medicine Clinic. New Patient Questionnaire

Thank you for making an appointment with our office. We look forward to serving your visual needs.

Cervical Spine. New Patient Form

REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:

NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH Phone: Fax:

WELCOME PATIENT CONDITION

Zabel Chiropractic Application For Care

SPINE PATIENT HISTORY FORM

AUTO ACCIDENT QUESTIONNAIRE

Motor Vehicle Accident - New Patient

DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS

1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU

Patient Information. Today s date: Your Name: Social Security Number: Date of Birth: Age: Height: Weight: lbs. Street Address: City/State/Zip:

Patient Medical History Form

PATIENT HEALTH QUESTIONNAIRE: Urology

Medicines To Treat Alcohol Use Disorder A Review of the Research for Adults

Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D

Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)

PATIENT REGISTRATION

Transcription:

Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr. Stokes at no charge. This however does NOT mean that your case has been accepted. Your consultation will determine if: A) You are a legitimate candidate and are qualified for this program and B) Your condition is serious enough to warrant your case being accepted for Treatment. If Dr. Stokes determines that your condition IS NOT serious enough to or you are not qualified for this program, Dr. Stokes let you know and do his best to give you some recommendations about where you need to go for help. I (Your Signature) consent to allow Dr. Stokes to: speak with me and perform an examination (if necessary) in order to determine if I am a good candidate for non-surgical spinal decompression therapy and also to determine if the doctor is willing to accept my case. PLEASE PRINT CLEARLY Today's Date _ Name Sex: M Fe Address City State Zip Age Birth date / / SS# - - Phone # s (home) (Work) (Cell) e-mail @_ Best Place To Reach You: Home Work Cell e-mail May we leave a message for you? Yes No Marital Status S M W D Spouses Name # of children Ages

PLEASE PRINT CLEARLY Employer Occupation Length of Employment Past Occupation if retired 1. How Did You Hear About The Spinal Decompression Center of Long Beach? 2. What Is Your Main Problem / Symptom Prompting Your Request For A Consultation With The Doctor? _ 3. How Serious Do You Think Your Problem Is? (check one) MINIMAL (Annoying but causing NO limitations) SLIGHT (Tolerable but causing a little limitation) MODERATE (Sometimes tolerable but definitely causing limitations) SEVERE (Causing Significant limitations) EXTREME (Causing near constant, 80% of the time or more, limitations) 4. In spite of the fact that you are not a back specialist, you are in fact the person who knows more about your back than anyone else. In your own words and in your own opinion what do you think the real problem is? 5. What are you hoping happens today as a result of your consultation with the Doctor? 6. Since your back pain became this severe what three things has it caused you to miss the most? 1. 2. 3. 7 How long have you had this problem? 8. How has your life changed since your back became a problem?

PLEASE PRINT CLEARLY 9. What kinds of treatments have you received for this condition? Medication: Which Drugs? Physical Therapy: How Long When (approx) Chiropractic: How Long When (approx) Acupuncture How long When (approx) Epidural injections: How Many When (approx) Surgery: Type_ When(approx) Other 10. Did any of these treatments work? If so which one(s)? For how long? 11. What can you do that makes it feel better? _ 12. What activities/movements are guaranteed to make it worse? 13. Please describe the quality of the pain. Sharp, Dull, Toothache, Shooting, Stabbing, Numb, Tingling, Other: 14. Is the pain worse in the morning or is it worse as the day progresses? 15. If you can not find a solution to this problem what will it be like in two years? _ 16. What do you hope or think the doctor might be able to do for you? Be able to work again without pain. Play golf /sports etc. Be able to sleep again. Be able to travel and see my kids / grandkids. Get out of constant pain and enjoy my life. Get off the drugs meds. Be able to sit though a ballgame or a show. Avoid surgery. Other, I am hoping to: 17. When is the VERY FIRST time you recall having this problem?

PLEASE PRINT CLEARLY 18. List In Order Of Importance all OTHER Health Problems/Concerns NOT including Your Main Problem. A. For How Long? B. For How Long? C. For How Long? D. For How Long? E. For How Long? 19. In Reference To Your MAIN PROBLEM How Often Are You Aware of it? Occasionally (25% of the time) Intermittently (50% of the time) Frequently (75% of the time) Constant (90-100% of the time) 20. Due To Your Main Problem... Have You Lost Any Time From Work? Yes No How Much Time? 22. What Tasks at work Have Been Limited? 23. Have You Lost Any Time From Your Chores/Tasks At Home? Yes No How Much Time? 24. What Tasks Have Been Limited? _ 25. Have You Lost Any Time From Your Family or leisure Activities, hobbies, sports, etc.? Yes No How Much Time? 26. What Activities Have Been Limited? 27. Considering the amount of pain / discomfort you've had THIS week, how long has your problem been this severe? 28. On a scale of 1-10 (10 being unbearable, (can t get out of bed) and 1 being No Pain or Discomfort) Please rate the following... The HIGHEST your pain gets WITHOUT medication The LOWEST your pain gets WITHOUT medication The HIGHEST your pain gets WITH medication The LOWEST your pain gets WITH medication

29. List ANY surgeries that you have had and the approximate dates. Surgery: Date: 30. Please List All Medication You Are Taking: 31. If you are a good candidate, qualify for spinal decompression therapy and the Doctor accepts you as a patient, is there someone else who will be involved in making the decision to begin care? Yes No If yes, Who would that be?

Have you had ANY of the following in the last 12 months or do you have them currently. C = Current. P = in the last 12 mos.) GENERAL C P Chills Convulsions Dizziness Fainting Fatigue Fever Headache Loss of Sleep Allergy (Tto what) Loss of Weight Nervousness Wheezing Bronchitis Numbness in BOTH Hands AND feet CARDIOVASCULAR High Blood Pressure Low Blood Pressure Pain over heart Poor Circulation Rapid Heartbeat Previous Heart Problem (Describe Slow Heartbeat Stroke TIA Swollen Ankles Varicose Veins Aortic Aneurysm Bruise Easily DISEASES / CONDITIONS Appendicitis Anemia Arthritis Alcoholism Abdominal Surgery Bleeding Disorder Blood Clot(s) Breathing Difficulty Cancer Cholesterol High Colon Problems Diabetes Depression Epilepsy Eating Disorder Glaucoma C P HIV + Heart Disease Hernia Headaches Influenza Kidney Disease Liver Disease Low back Pain Mental Illness Measles Mumps Pleurisy Pneumonia Polio Prostate Problems Hyperthyroid Hypothyroid Rectal Surgery EARS / EYES / NOSE / THROAT Asthma Crossed Eyes Double Vision Blurred Vision Difficulty Swallowing Deafness Hearing Loss Ear Pain Thyroid Problem Nose Bleeds Sinus Problems Sore Throats GASTRO-INTESTINAL Gas Colon Trouble Constipation Diarrhea Gallbladder Trouble Hemorrhoids Liver Trouble Nausea Stomach Ache Poor Appetite Poor Digestion Vomiting Vomiting Blood Rectal Bleeding Bloating GENITO-URINARY C P Blood in Urine Frequent Urination Inability to control urine Kidney Infection Painful Urination Prostate Trouble Painful Urination FOR MEN ONLY Lump in testicles Penis discharge Can t achieve or maintain an erection FOR WOMEN ONLY Menstrual Cramps Excessive menstrual flow Hot Flashes Irregular Cycle Painful periods Birth Control Pills Abnormal Pap Smear MUSCLE / JOINT / BONE Backache Foot Trouble Pain Between Shoulders Painful Tailbone Stiff Neck Spinal Curvature Swollen Joints NEUROLOGIC Seizures Dizziness Hand Trembling Weakness Difficulty with speech Loss of memory Loss of coordination RESPIRATORY Chest Pain Chronic Cough Difficulty Breathing Coughing/Spitting Blood Signature Date

2026 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information