Demographics

Provider

Appointment
  

Patient Name *
   

Gender *  
  Male      Female 

Marital Status *
 
 

Social Security Number  

Birth Date *
 

Ethnicity *   

Race *   

Preferred Language

Primary Care Physician
(enter “none” if none)

Patient Address *
     

Patient Phone *  
 

E-Mail Address

Employment Status *

If Retired/Disabled, Date of Retirement/Disability

Employer/School *
     

Reason for Visit *

Advanced Directive? *
 Yes    No


Encounter Information

Date & Time of Accident/Injury *

Due to a Motor Vehicle Accident? *
 Yes    No

Due to a Workmans’ Comp Injury? *
 Yes    No


Guarantor/Patient Information
(if patient is a MINOR – info for person receiving Billing Statement)

Name
 

Social Security Number
 

Birthdate

Relationship to Patient

Guarantor Address
     

Guarantor Phone
 

Guarantor Employer
  


Primary Insurance

Do you have insurance? Yes     No


Subscriber’s Name

Relationship

Birth Date

Social Security Number

Subscriber’s Home Address

Employer Information
  
 Full    Part-time

Insurance Information
       


Secondary Insurance

Do you have secondary insurance? Yes   No


Subscriber’s Name

Relationship

Birth Date

Social Security Number

Subscriber’s Home Address

Employer Information
  
 Full    Part-time

Insurance Information
     


Emergency Contact

Name *

Birth Date *

Gender *
  Male      Female


Primary Phone *

Relationship to Patient *


Health History

Patient Information *
     

Referred by *
 

Primary Physician *
 

Current Injury/Complaint

Chief Complaint *
  Right      Left      Bilateral

Body part *

History of Present Illness: Answer these questions regarding your current problem(s) only.

What symptoms are you experiencing? How did it happen? *

How long have you had this problem? *

What is the date of injury? *

Is this a sports-related injury? *
  Yes    No

If yes, please name school/club

Is this the result of an auto accident? *
  Yes    No

Date of injury

Is this a Workers’ Compensation case? *  
  Yes    No

Date of injury

Do you have an attorney assisting you? *
  Yes    No

Is there any other legal action pending? *
  Yes    No

Check any previous treatment(s) you’ve had for this problem if applicable:
 Anti-Inflammatories/NSAIDS  
 Bracing  
 Chiropractor  
 Cold Therapy  
 Emergency Room  
 Injection  
 Medication  
 Physical Therapy  
 Relaxation/Rest  
 Repositioning  
 Surgery  
 None  
 Other Treatments  

Have you had any of the following diagnostic studies for your current problem?

CT *
  Yes     No

 

EMG/NCV *
  Yes     No

 

Epidural/steroid injection *
  Yes     No

 

MRI *
  Yes     No

 

Myelogram *
  Yes     No

 

X-Rays *
  Yes     No

 

Other *
  Yes     No

 

On a scale of 1-10, how severe is your pain? (0 = no pain present - 10 = worst pain of your life) *

Pain Description:
  Aching  
  Burning 
  Dull  
  Numbness  
  Pressure  
  Sharp  
  Shooting 
  Throbbing  
  Tingling
  Unable to describe
  Other  

Do any of the following activities make it worse? (Check all that apply)
  Activities of Daily Living  
  Exercise  
  Lifting  
  Lying Down  
  Rising from a Chair  
  Sitting  
  Standing  
  Walking
  Other


Medications

Allergies to medications, X-ray dye, metals and/or soaps?
 
No Known Allergies
 
Yes, please list and indicate reaction




Please list all current medications and dosages, or bring current list to your scheduled appointment *
I am currently not taking any medications prescribed or over-the-counter
I am currently taking medications prescribed or over-the-counter












Pharmacy *
   


Social History

Do you use any of the following? (check all that apply)

Smoking Tobacco *
  Never
 Current
 Former

Date Quit

Smokeless Tobacco *
  Never
 Current
 Former

Date Quit

Electronic Cigarettes/Vaping *
  Never
 Current
 Former

Date Quit

Alcohol
Current
1-2 times per   Week   Month   Year
Past  
Never

Non-prescription, mind-enhancing drugs or performance enhancing drugs (please list)

Do you exercise regularly *
  Yes     No

How many times per week
  Daily     1-2     3-4     5-6

Employer

  Retired    Disabled     Unemployed

What kind of work do you do
 

Are you a student?
  Yes     No

If yes, please list your grade and school name

Family History - check where applicable

Anesthesia Problems
Father   Mother   Sister   Brother

Cancer
Father   Mother   Sister   Brother

Bleeding/Clotting (DVT) 
Father   Mother   Sister   Brother

Diabetes
Father   Mother   Sister   Brother

Gout
Father   Mother   Sister   Brother

Heart Disease
Father   Mother   Sister   Brother

High Blood Pressure
Father   Mother   Sister   Brother

Stroke
Father   Mother   Sister   Brother

Past Medical History - check all that apply

  Heart Disease
  Lung Disease
  Asthma
  Diabetes
  Gastric Ulcer
  Anxiety
  Depression
  Osteoarthritis
  Stroke
  Dementia
  High Blood Pressure
  Cancer
  Kidney Disease
  Blood Disorder
  Thyroid Disorder
  Osteoporosis
 Liver Disease
  Fibromyalgia
  Gout
  Skin Infection
  MRSA
  Cellulitis
  Sleep Apnea/C-PAP
  Blood Clots/DVT
  Pulmonary Embolism
  Multiple Sclerosis
  Claustrophobia
  Hepatitis     A     B     C
  HIV
  Reaction to Anesthesia
  Other  
  Other  

Procedure History - Please list all past procedures

None
Orthopaedic (procedure and date)

Stent Placement (date)

Heart Bypass (date)

Other

Pacemaker
Hysterectomy
Appendectomy
Gallbladder
Sinus
C-Section
Tubal Ligation
Tonsils
Tubes (ear)
Vasectomy


Review of Systems
Mark current systems

Constitutional
  Normal
  Chills
  Fever
  Night Sweats
  Obesity
  Weight Change

Cardiovascular
  Normal
  Chest Pain
  Difficulty Breathing

Hema/Lymph
  Normal
  Bleeds Easy
  Bruises Easy

Musculoskeletal
  Normal
  Other Joint Pain

Psychiatric
  Normal
  Depression
  Anxiety

HEENT
  Normal
  Headache
  Hearing Loss
  Tooth Pain
  Visual Problems

Gastrointestinal
  Normal
  Heartburn/Acid Reflux
  Nausea
  Vomiting

Endocrine
  Normal
  Excessive Sweating
  Excessive Thirst

Integumentary
  Normal
  Rashes
  Skin Lesions

Respiratory
  Normal
  Shortness of Breath

Genitourinary
  Normal
  Urinary Frequency
  Urinary Incontinence

Immunologic
  Normal
  Seasonal Allergies
  Swollen Neck Glands

Neurologic
  Normal
  Motor Disturbances
  Numbness
  Tingling
  Vertigo/Dizziness


Health Promotion

Have you been discharged from a nursing facility, hospital or skilled rehabilitation facility in the last 30 days? *
  Yes     No

Are you 64 years of age or older?

  Yes     No

Advanced Care Planning
Do you have an Advance Directive?  
  Yes     No
If yes, please consider providing a copy for your medical record at your next visit

Are you interested in receiving additional information on Advanced Directives?
  Yes     No

Fall Prevention
Are you non-ambulatory (wheelchair bound or bedridden)?
  Yes     No

Have you fallen in the past year?
  Yes     No  

If yes, how many times  
 

If yes, were you injured?  
  Yes     No

Do you feel unsteady standing or walking?
  Yes     No   

Do you worry about falling?  
  Yes     No


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