New Patient Intake Form · 2019-09-20 · Shade the areas where you pain or concern Circle the...
Transcript of New Patient Intake Form · 2019-09-20 · Shade the areas where you pain or concern Circle the...
New Patient Intake Form
Patient Name: E-mail
Birthday: Age Sex: Male/Female
Referring Physician
Family Physician
Other Health Care Providers Involved with Your Care:
Neurosurgeon Orthopedic Surgeon
Pain Management Specialist Psychologist/Psychiatrist
Physical Therapist Chiropractor
Other
1. Chief Complaint-What is the reason for your visit to our office
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2. Onset -When did the pain or the concern(s) starts?Was the start of the pain or concern?
suddengradual
3. Cause of Pain-What started your pain?
Work related accident or event?
yesno
If yes, date
Is this under Workers Compensation?
yesno
If yes, Case #
Motor vehicle accident
yesno
If yes, date
Unknown
yesno
If yes, date
Other (briefly explain)
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4. Location-Where are your symptoms? Shade the areas where you pain or concern Circle the areas where you have numbness/tingling XXX the areas where you have weakness
NOTE: If you are being seen for Neck pain, answer questions 5-12 and skip questions 13-20. If you are being seen for Back pain, skip questions 5-12 and answer questions 13-20.
Neck Pain History (questions 5-12)
5. Quality--Which of the following describes your Neck pain? Check all Boxes that apply
Aching Agonizing Annoying BurningCold Constricting Cramping DeepDisabling Dull Exhausting FearfulHeavy Horrible Hot ItchingNagging Numb Pressure PulsatingSharp Shooting Sickening StabbingSuperficial Tender Throbbing TinglingTiring Toothache-like Uncomfortable WeakeningOther
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6. Quality--Which of the following describes your Arm pain? Check all Boxes that apply If the same symptoms are present as in Neck pain? (If yes, then go to questions 7) It's Different than the neck pain (Circle all that apply)
I have symptoms in: Right Arm Left Arm Both Arms
Aching Agonizing Annoying BurningCold Constricting Cramping DeepDisabling Dull Exhausting FearfulHeavy Horrible Hot ItchingNagging Numb Pressure PulsatingSharp Shooting Sickening StabbingSuperficial Tender Throbbing TinglingTiring Toothache-like Uncomfortable WeakeningOther
Pain Scale Rating: 0 = no pain, 10 = as bad as it gets
7. Please rate your Neck pain
0 1 2 3 4 5 6 7 8 9 10
At its worse
At its best
Now
Average
8a. Please rate your Right Arm pain
If the same symptoms are present as in Neck pain? (If yes, then go to questions 7) It's Different than the neck pain (Shade all that apply)
0 1 2 3 4 5 6 7 8 9 10
At its worse
At its best
Now
Average
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Does the pain, numbness or tingling radiate down the Left Arm? Shoulder Elbow Wrist Fingers
8b Please rate your Left Arm pain
If the same symptoms are present as in Neck pain? (If yes, then go to questions 7) It's Different than the neck pain (Shade all that apply)
0 1 2 3 4 5 6 7 8 9 10
At its worse
At its best
Now
Average
9. Better --- What makes your Neck pain better
Acupuncture Activity AlcoholApplying Pressure Bending Changing PositionChiropractic care Exercise Cold/IceHeat Lying Down MedicationMassage Nerve Blocks NothingPhysical Therapy Relaxation Therapy RestSitting Sleeping StandingStretching TENS Unit Using a BraceWarm Bath/Shower WalkingOther
10. Better --- What makes your Arm pain better
If the same symptoms are present as in Neck pain? (If yes, then go to questions 11 ) It's Different than the neck pain (fill in the blanks below)
Acupuncture Activity AlcoholApplying Pressure Bending Changing PositionChiropractic care Exercise Cold/IceHeat Lying Down MedicationMassage Nerve Blocks NothingPhysical Therapy Relaxation Therapy RestSitting Sleeping StandingStretching TENS Unit Using a BraceWarm Bath/Shower WalkingOther
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Does the pain, numbness or tingling radiate down the Left Arm? Shoulder Elbow Wrist Fingers
11. Worse --- What makes your Neck pain worse (x on all that apply)
Activity Bending Bowel MovementsClimbing Stairs Coughing ExerciseLifting Lying Down MotionNerve Blocks Nothing Physical TherapyPulling Pushing SexSitting Sleeping SneezingSquatting Standing StressStretching Stooping Surgery Made it WorseTwisting Using a Brace WalkingWeather Changes Other
12. Worse --- What makes your Arm pain worse (x on all that apply)
If the same symptoms are present as in Neck pain? (If yes, then go to questions 21) It's Different than the Neck pain (fill in the blanks below)
Activity Bending Bowel MovementsClimbing Stairs Coughing ExerciseLifting Lying Down MotionNerve Blocks Nothing Physical TherapyPulling Pushing SexSitting Sleeping SneezingSquatting Standing StressStretching Stooping Surgery Made it WorseTwisting Using a Brace WalkingWeather Changes Other
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Back Pain History (questions 13-20)
13. Quality--Which of the following describes your Back pain? Check all Boxes that apply
Aching Agonizing Annoying BurningCold Constricting Cramping DeepDisabling Dull Exhausting FearfulHeavy Horrible Hot ItchingNagging Numb Pressure PulsatingSharp Shooting Sickening StabbingSuperficial Tender Throbbing TinglingTiring Toothache-like Uncomfortable WeakeningOther
14. Quality--Which of the following describes your Leg pain? Check all Boxes that applyIf the same symptoms are present as in Back pain? (If yes, then go to questions 15)It's Different than the back pain (Circle all that apply)
I have symptoms in: Right Leg Left Leg Both Legs
Aching Agonizing Annoying BurningCold Constricting Cramping DeepDisabling Dull Exhausting FearfulHeavy Horrible Hot ItchingNagging Numb Pressure PulsatingSharp Shooting Sickening StabbingSuperficial Tender Throbbing TinglingTiring Toothache-like Uncomfortable WeakeningOther
Pain Scale Rating: 0 = no pain, 10 = as bad as it gets
15. Please rate your Back pain
0 1 2 3 4 5 6 7 8 9 10
At its worse
At its best
Now
Average
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16a. Please rate your Right Leg pain
If the same symptoms are present as in Back pain? (If yes, then go to questions 17) It's Different than the back pain (Shade all that apply)
0 1 2 3 4 5 6 7 8 9 10
At its worse
At its best
Now
Average
Does the pain, numbness or tingling radiate down the Right leg? Hip Buttock Thigh Knee Lower Leg Foot Toes
16b. Please rate your Left Leg pain
If the same symptoms are present as in Back pain? (If yes, then go to questions 17) It's Different than the back pain (Shade all that apply)
0 1 2 3 4 5 6 7 8 9 10
At its worse
At its best
Now
Average
17. Better --- What makes your Back pain better
Acupuncture Activity AlcoholApplying Pressure Bending Changing PositionChiropractic care Exercise Cold/IceHeat Lying Down MedicationMassage Nerve Blocks NothingPhysical Therapy Relaxation Therapy RestSitting Sleeping StandingStretching TENS Unit Using a BraceWarm Bath/Shower WalkingOther
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Does the pain, numbness or tingling radiate down the Left leg? Hip Buttock Thigh Knee Lower Leg Foot Toes
18. Better --- What makes your Leg pain better
If the same symptoms are present as in Back pain? (If yes, then go to questions 11 ) It's Different than the back pain (fill in the blanks below)
Acupuncture Activity AlcoholApplying Pressure Bending Changing PositionChiropractic care Exercise Cold/IceHeat Lying Down MedicationMassage Nerve Blocks NothingPhysical Therapy Relaxation Therapy RestSitting Sleeping StandingStretching TENS Unit Using a BraceWarm Bath/Shower WalkingOther
19. Worse --- What makes your Back pain worse (x on all that apply)
Activity Bending Bowel MovementsClimbing Stairs Coughing ExerciseLifting Lying Down MotionNerve Blocks Nothing Physical TherapyPulling Pushing SexSitting Sleeping SneezingSquatting Standing StressStretching Stooping Surgery Made it WorseTwisting Using a Brace WalkingWeather Changes Other
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20. Worse --- What makes your Leg pain worse (x on all that apply)
If the same symptoms are present as in Back pain? (If yes, then go to questions 21) It's Different than the Back pain (fill in the blanks below)
Activity Bending Bowel MovementsClimbing Stairs Coughing ExerciseLifting Lying Down MotionNerve Blocks Nothing Physical TherapyPulling Pushing SexSitting Sleeping SneezingSquatting Standing StressStretching Stooping Surgery Made it WorseTwisting Using a Brace WalkingWeather Changes Other
21. Prevalence --- How often do you have pain? (x on all that apply)
Rarely IntermittentlyNot Daily Some DailyMost of the time Daily Constant with VariationConstant with No Change
22. Progression --- How is your pain changing? (x on all that apply)
Getting Better Getting WorseNo Change Since Pain Started
23. Sleeping ---- How has your sleep changed due to pain? (x on all that apply)
No difficulty with sleep
Difficulty falling sleep:
occasionallyfrequentlynightly
Difficulty staying asleep
occasionallyfrequentlynightly
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24. Testing --- What testing have you had RECENTLY? (x on all that apply)
Biopsy Bone ScanCT Scan DEXA ScanDiscogram EMG/Nerve Conduction TestFunctional Capacity Test MRIMyelogram Nerve BlocksPain Injections Spinal TapX-RaysOther
25. Treatment ---- What treatments have you had to resolve your issue? (x on all that apply)
Aerobic ExerciseBiofeedbackChiropractor ManipulationHypnotherapyMassage TherapyPain MedicationPool ExerciseRelaxation TherapySteroid PillsTENS Unit
BedrestBracing Cryoanalgesia Morphine Pump NonePhysical Therapy Radiofrequency Spinal Cord Stimulator Therapeutic Injections TractionPain InjectionsWork Modification
Other
26. Medical History (x on all that apply)
HEENT Cataracts BlindnessDeafness Hearing AidsEnvironmental AllergiesOther
Respiratory: Asthma Chronic BronchitisCOPD EmphysemaSarcoidosis Pulmonary EmbolusSleep Apnea CPAP/BIPAP useOther
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Specify all of your therapies that were attempted along with length or period of time that you tried them.
Cardiovascular Heart Disease High Blood PressureHigh Cholesterol Heart AttackDVT(blood clot) PacemakerDefibrillator Heart ArrhythmiaHeart Failure (CHF) Heart MurmurOther
Gastrointestinal Crohn's Disease GERD/ Acid RefluxHepatitis Liver DiseasePeptic Ulcer Disease Irritable BowelOther
Urinary Kidney Disease Kidney Stones Kidney TransplantOther
OB/GYN: ( women only) Post -Menopausal for how many years
Orthopedic Osteoarthritis ScoliosisJoint Surgeries Other
Rheumatologic: Ankylosis Spondylolitis FibromyalgiaGout LupusOsteoarthritis Rheumatoid ArthritisOther
Neurologic Alzheimer's Brain TumorClosed Head Injury StrokeChiari Malformation Multiple SclerosisMigraine ParalysisDiabetic Neuropathy Guillan-BarreSeizure EpilepsyOther
Psychiatric Anxiety Bipolar DepressionOther
Endocrine Diabetes Hyperthyroid HypothyroidOsteopenia OsteoporosisOther
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Hematologic AnemiaProlonged BleedingHemophiliaOther
Infectious HIV/AIDS Tuberculosis Hepatitis BHepatitis C MRSA InfectionOther
Surgery Problems
Trouble Awakening Post Op Nausea/ VomitingSuture ReactionOther
Cancer: Where/Type
27. Past Spine Problems/ Injuries/ Surgeries
Type of Problem/ Surgery Treating Physician/Surgeon Date of Occurence
28. Surgical History- list of all the other surgeries you have had in the past:
Date Surgery Type
29. Social History
I am : Right Handed Left Handed Ambidextrous
Tobacco: NonsmokerSmoker
Packs per day
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Quit Smoking X Years Ago Years of Smoking
Alcohol: Drinks per
week on average
none 1-23-6 7-1415+ Choice 1Other
Prescription Drug History
No history of abuse/addictionHistory of abuse/addictionCurrently addicted to pain medicationOther
Illegal Drug History
No History of drug abuse/addictionHistory of abuse/addictionCurrently addicted to illegal drugsOther
30. Family History (mark all that apply)
Father Mother Child Grand- Sister or Brother
Other
Alcoholism
Back/Neck Problems
Chronic Pain
Diabetes
Drug Addiction
Heart Disease
Kidney Disease
Rheumatoid Arthritis
Cancer (List Kind)
Other
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Other_____________________________________________________________________________________
parent
31. Medications
Name of Medication Dose/ Frequency Reason for Taking?
32. Allergies
Name of medication or source What reaction does it cause?
Review of Symptoms (x all that apply)
General Weight Loss Weight Gain FatigueFever Chills Night SweatsWeaknessOther
Head Trauma Headache ConcussionOther
Eyes Vision Loss Blurriness GlaucomaGlasses Contact Lenses Cataract SurgeryOther
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Ears Hearing Loss Ringing in the earsDizziness EaracheHearing AidsOther
Nose Chronic Nasal Congestion NosebleedsSnoringOther
Throat/Neck Bleeding Gums HoarsenessSore Throat Difficulty SwallowingSwollen Neck Neck Lumps/MassesOther
Respiratory Shortness of Breath WheezingOxygen usageOther
Cardiovascular Palpitations Chest PainLeg Swelling Leg Pain while WalkingOther
Gastrointestinal Loss of Appetite NauseaVomiting IndigestionConstipation DiarrheaBloody Stools Black/Tarry StoolsAbdominal Pain Inability to control bowelsOther
Urinary Difficulty Emptying Bladder Sexual DysfunctionInability to Control BladderOther
Bone & Joint Joint Stiffness Achy JointsSwelling Joints Redness of JointsDaytime Muscle CrampsOther
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Neurological Muscle Weakness Tremors FaintingBlackouts Loss of BalanceMemory ProblemsChoice 2Other
Psychiatric Changes in Mood Changes in Stress/TensionAnxiousness SadnessThoughts of Suicide Panic AttacksOther
Signature
Completing this questionnaire will help us to serve you substantially better. Be sure to bring this with you to your appointment. Please bring all insurance information. Bring the CDs of your imaging studies! Bring all of your reports as well. Thank You!
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