COMPREHENSIVE SPINE CENTER



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

PATIENT HISTORY FORM

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

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

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

Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE

Cervical Spine. New Patient Form

New England Pain Management Consultants At New England Baptist Hospital

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

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION

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

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

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

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

New Patient Intake Form

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

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER

PATIENT DEMOGRAPHICS

SPINE PATIENT HISTORY FORM

Emory Eye Center New Patient Questionnaire

PATIENT INFORMATION INSURANCE INFORMATION

NEW PATIENT INFORMATION FORM

General Internal Medicine Clinic New Patient Questionnaire

Interventional Spine Pain Consultants, P.A. Initial Consultation Information

North Carolina Orthopaedic Clinic Patient Registration Form

PODIATRIC ASSOCIATES OF NW OHIO, INC. PATIENT HISTORY INSURANCE INFORMATION

PLEASE PRINT LEGIBLY

Interventional Spine Care New Patient History and Intake Form

PATIENT SELF-ASSESSMENT FORM

PATIENT REGISTRATION FORM

Plano Heart Center, P.A.

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

PAIN MANAGEMENT. Patient s name: IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.

NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute

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

NEW PATIENT HISTORY Mark L. Prasarn, M.D.

Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Primary Care Physician: Pharmacy: Pharmacy Phone #:

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone address

Women s Continence and Pelvic Health Center

Surgery Health Survey

Rehabilitation Medicine Clinic. New Patient Questionnaire

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

Pulmonary Associates of Richmond

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

MEDICAL HISTORY AND SCREENING FORM

Workman s Compensation

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

NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE

CAMARILLO AQUATICS AND REHABILITATION SERVICES

OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD

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

Dr. Kenneth A. Giraldo, MD, P.A. Patient Controlled Substance Agreement Informed Consent Form

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

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

How to Remove a Social History Smoke?

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

RETINA CARE CENTER, P.C. PATIENT INFORMATION

LIST ALL MEDICATIONS (BOTH PRESCRIBED AND OVER THE COUNTER) AND SUPPLEMENTS

Function First Physical Therapy, P.C. Patient Intake Form

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

Medical Massage Client Intake Form Medical Massage Client Intake Form

PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet

TOTAL PAIN RELIEF. Also bring your medication so that we can review them with you and help answer any question you may have.

INITIAL PATIENT QUESTIONNAIRE-

Patient Information Form Pain Management Center at Phoebe

Texas Sinus Center PATIENT REGISTRATION. Name Birth date Soc Sec# Address City/State Zip

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

Personal Injury Questionnaire

Welcome to the UW Health Sports Medicine Clinic

Princeton and Rutgers Neurology, P.A. A Center Of Excellence

New Patient Evaluation

CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850

Notice of Privacy Practices

PATIENT DEMOGRAPHICS & INSURANCE INFORMATION

New Patient Registration Information

Florida Digestive Specialists Gastroenterology and Liver Disease Management Over 30 Years of Service

WORKERS COMPENSATION INTAKE FORM

PATIENT REGISTRATION FORM

Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:

PATIENT DEMOGRAPHICS:

MEDICAL HISTORY INFORMATION

Hello, Please note: The following information will be needed at your appointment:

PATIENT HEALTH QUESTIONNAIRE: Urology

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

DEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION

Transcription:

Dear Esteemed Patient: CSC Physicians: Ulrich Batzdorf, MD; David E. Fish, MD; Langston Holly, MD; Jae Jung, MD; Duncan Q. McBride, MD; Don Y. Park, MD; Nick Shamie, MD; Daniel Lu, MD, PhD COMPREHENSIVE SPINE CENTER 1131 Wilshire Blvd, Suite 100 Santa Monica, CA 90401 310-319-DISK (Appointment) 424-259-6930 (Fax) Thank you for choosing to make an appointment at the UCLA Spine Center located at 1131 Wilshire Blvd, Suite 100 in Santa Monica. Please be sure to bring the following to your appointment: o Your most current diagnostic films and reports (e.g. MRI, CT, plain x-rays; SSEP or EMG reports; Physical Therapy reports; Pain Medicine reports, etc.) pertaining to your current medical condition. (PLEASE NOTE: If your films were done within the UCLA system at Santa Monica or Westwood, our office will make sure that they are here for your visit and you do not need to pick up these films. However, if you had films done outside of UCLA, you do need to bring these with you). o o o o Prior medical records and consultations from your referring physician and any other specialist you've seen for your current condition. To help expedite your visit, please hand carry your reports to this office. Do not send them prior to your appointment. Your medical insurance card (s) If you have HMO Insurance: Please be sure to bring your "Letter of Authorization: from your HMO. If you do not bring your authorization letter and we do not have written authorization on file, you will be financially responsible and will be asked to pay the consultation fee on the day of your appointment. If you have HMO Insurance: Please be sure to bring your co-payment with you. We accept cash, check, or Visa/Mastercard. Attached you will find a questionnaire and a map with directions to our location. Please bring in the completed paperwork to your appointment. If you have any questions, please feel free to contact the UCLA Spine Center Appointment Scheduling desk at (310) 319-3475. We look forward to seeing you. PLEASE NOTIFY US OF ANY CANCELLATIONS AT LEAST 24 HOURS PRIOR TO YOURAPPOINTMENT On your initial visit you will be seen by the Orthopaedic Spine Specialist, Don Y. Park, MD, who will, with or without a Spine Fellow and /or Resident and /or Physician's Assistant and /or Nurse Practitioner student, obtain a medical history and perform a physical examination. The SM/UCLA Comprehensive Spine Center advocates a multi-disciplinary approach to strive and attain the best possible healing and recovery for every patient. Because every patient is unique, we prescribe treatment based on a thorough evaluation, that we perform utilizing the latest technological advancements available. We believe in evaluating patients promptly and educating them on their diagnosis, so they can play an active role in the decision-making and treatment process. Our physicians' clinical experience has shown that patients who participate in their own health care decisions are far more likely to achieve an optimal level of healing and recovery. Sincerely, Patient Care Coordinator SM/UCLA Comprehensive Spine Center

Date: Please take the time to answer a few questions regarding your symptoms. Pain Diagram Please draw out your symptoms on the diagram below using the following symbols: Numbness: 00000 Pins & Needles: ------ Stabbing: ////// Burning: xxxxx History: Age: Gender: Chief complaint: What is your dominant hand? Right Left Date of injury? What is your current pain level? [0 1 2 3 4 5 6 7 8 9 10] (Please circle; 0: no pain, 10: worst pain imaginable) When did your symptoms first start? When did your symptoms get worse? What is worse: your neck back pain your arm leg pain? Is your pain: Constant Intermittent Occasional? Is your pain: Getting better Getting worse Staying the same? Page 2 of 6

Is your pain worse: When first getting up from bed? At the end of the day? When changing positions? What makes your pain worse? (sitting, standing, walking, bending forward, leaning back, twisting, etc) What makes your pain better? (sitting, standing walking, lying down, bending forward, leaning back, etc) Are you having any of the following difficulties? (Please check if applicable) Loss of bladder control Urgent desire to urinate Loss of bowel control Loss of sensation in genitalia and anal region Difficulty walking Limping Use of cane, crutch, or walker Use of wheelchair Problems with balance I have none of these Do you have any weakness? Arms Hand Legs Feet Do you have numbness or tingling? Where? Do you have headaches associated with your symptoms? Are you having any difficulty handling small objects? (pins, coins, needles, buttons, etc) Have you had a steroid injection in the past? When? Did the injection help? Have you had physical therapy in the past? When? Did physical therapy help? Any previous treatments for your symptoms? (Chiropractor, acupuncture, injections, previous surgery) Any improvement? What pain medicines are you using now? Any relief? Page 3 of 6

Please take the time to complete this form to better understand your history. Past Medical History (Please check YES or NO for any significant conditions) Anemia Heart Defect Asthma Heart Attack Arthritis Heart Failure Alcohol dependency High Blood Pressure Arrhythmia High Cholesterol Anxiety Immune Disorder Bleeding/Bruising Intestinal Problems Blood Disorder Kidney Disease COPD Liver Disease Chronic Bronchitis Migraine/Headache Cancer Osteoporosis Depression Obesity Diabetes Stroke Drug Abuse Sinus problems Epilepsy/Seizures Thyroid Disease Emphysema Tuberculosis (TB) Hay Fever Stomach Ulcers Other (Please list): - Past Surgical History (Please list all surgeries and approximate dates) Medications (Please list name, dose, and frequency of all medications) Allergies (Please list all medication and latex allergies and describe reaction) Page 4 of 6

Social History Do you smoke cigarettes? Packs per day? How many years? If you quit, when? Do you use any other forms of tobacco? What type? Do you drink alcohol? How often and how much? Do you use drugs other than prescribed or over the counter medications? What do you use? Birthplace? Marital Status/Relationship? Current Occupation: Family History (Please list medical problems in your family) Age Medical Problems If decreased, cause of death Father Mother Siblings Children Grand- Parent Page 5 of 6

Review Review of Systems: (Please check if applicable) None are applicable General Good health Recent w eight changes Fatigue Recurrent fever or chills Headache Skin/Breast Rashes Lumps Itching Color changes Hair and nail changes Pain Discharge Ear/Nose/Throat Decreased hearing Ringing in ears Pain Drainage Stuffiness Discharge Nosebleeds Sinus pain Dry mouth Sore throat Hoarseness Non-healing sores Bleeding Swollen glands Eyes Glasses or contacts Pain Redness Blurry or double vision Glaucoma Cataracts Respiratory Cough Sputum Coughing up blood Shortness of breath W heezing Painful breathing Cardiovascular Chest pain or discomfort Tightness Palpitations Shortness of breath with activity Difficulty breathing lying down Swelling Sudden awakening from sleep with shortness of breath Gastrointestinal Swallowing difficulties Heartburn Change in appetite Nausea Change in bowel habits Rectal bleeding Constipation Diarrhea Yellow eyes or skin Genitourinary Frequency Urgency Burning or pain Blood in urine Incontinence Change in urinary strength Male- Pain with sex Hernia Penile discharge Sores Masses or pain Erectiledysfunction ST D s Female- Pain with sex Vaginal dryness Hot flashes Vaginal discharge Itching or rash ST D s Vascular Calf pain with walking Leg cram ping Varicose veins Musculoskeletal Muscle or joint pain Stiffness Back pain Redness of joints Swelling of joints Trauma Neurologic Dizziness Fainting Seizures W eakness Numbness Tingling Tremor Hematologic Ease of bruising Ease of bleeding Endocrine Heat or cold intolerance Sw eating Frequenturination Excess thirst Change in appetite Psychiatric Nervousness Depression Memory loss Stre s : Name of person completing form Signature: Relationship (if other than patient): Page 6 of 6

Health Questionnaire English version for the US US (English) 1998 EuroQol Group. EQ-5D is a trade mark of the EuroQol Group

By placing a checkmark in one box in each group below, please indicate which statements best describe your own health state today. Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed 2 US (English) 1998 EuroQol Group. EQ-5D is a trade mark of the EuroQol Group

To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today. Best imaginable health state 100 9 0 8 0 7 0 6 0 Your own health state today 5 0 4 0 3 0 2 0 1 0 0 3 US (English) 1998 EuroQol Group. EQ-5D is a trade mark of the EuroQol Group Worst imaginable health state

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