PATIENT INFORMATION

Today’s Date______

Name: Last:______First:______MI:______Sex M F

Date of Birth:_____/_____/_____ Age:______Social Security #______

Phone: Home:______Cell:______Work:______

E-Mail Address:______

Mailing Address:______City:______St:______Zip:______

Emergency Contact:______Phone:______

Relationship:______

Physicians Information-Important, please complete:

Referring Physician:______Phone: ( )______

Address:______City:______St:______Zip:______

IF DIFFERENT FROM ABOVE

Primary Care Physician:______Phone: ( )______

Address:______City:______St:______Zip:______

INSURANCE INFORMATION

Primary Insurance Name______

Insurance Subscriber______Date of Birth______

Relation to Subscriber______Policy Number______Group Number______

Effective Date______Policy Holder’s Employer______

Secondary Insurance Name______

Insurance Subscriber______Date of Birth______

Relation to Subscriber______Policy Number______Group Number______

Effective Date______Policy Holder’s Employer______

Worker’s Comp/Auto______

Case Manager/ Nurse: Name______Phone:______

Case Number:______

Send Bills to: Name______

Address: ______

______

______

SYMPTOMS for conditions you currently have or have had in the past ONE year.

GENERAL EYE, EAR, NOSE, THROAT PSYCHIATRIC

Chills / Y N / Difficulty Swallowing / Y N / Disturbing Thoughts / Y N
Fever / Y N / Vision-flashes / Y N / Memory Loss / Y N
Dizziness / Y N / Sinus Problems / Y N / Psychatric Disorders / Y N
Fainting / Y N / Nosebleeds / Y N / Hallocinations / Y N
Depression / Y N / Persistent Cough / Y N / NEUROLOGICAL
Forgetfulness / Y N / Loss of Hearing / Y N / Loss of Consciousness / Y N
Headache / Y N / Ringing in Ears / Y N / Blackouts / Y N
Loss of Sleep / Y N / Coughing Blood / Y N / Fainting / Y N
Loss of Weight / Y N / Tremors / Y N
Nervousness / Y N / Head Injury / Y N
Numbness / Y N / Strokes / Y N
MUSCLE/JOINT/BONE
Pain, weakness,
numbness in: / GASTROINTESTINAL / CARDIOVASCULAR
Arms / Y N / Hips / Y N / Appetite Poor / Y N / Chest Pain / Y N
Back / Y N / Legs / Y N / Bloating / Y N / Irregular Heart Beat / Y N
Feet / Y N / Hands / Y N / Bowel Changes / Y N / Low Blood Pressure / Y N
Neck / Y N / Shoulder / Y N / Constipation / Y N / High Blood Pressure / Y N
Back Problems / Y N / Diarrhea / Y N / Poor Circulation / Y N
Muscle Cramps / Y N / Excessive Thirst / Y N / Rapid Heart Beat / Y N
Restricted Motion / Y N / Loss of Bowel Control / Y N / Swelling of Legs / Y N
Muscle Stiffness / Y N / Hemorrhoids / Y N / Varicose Veins / Y N
Joint Stiffness / Y N / Indigestion / Y N / Short of Breath / Y N
Paralysis / Y N / Nausea / Y N / Short of Breath-Sleeping / Y N
Rectal Bleeding / Y N / Short of Breath-Exertion / Y N
Stomach Pain / Y N / Short of Breath-Lying Flat / Y N
Vomiting / Y N / Thrombophelebitis / Y N
Vomiting Blood / Y N / Heart Murmur / Y N

CONDITIONS for conditions you currently have or have had in the past ONE year.

AIDS/HIV / Y N / Chicken Pox / Y N / Kidney Stones / Y N / Prostate Problems / Y N
Angina / Y N / Diabetes / Y N / Kidney Disease / Y N / Psychiatric Care / Y N
Anemia / Y N / Emphysema/COPD / Y N / Liver Disease / Y N / Rheumatic Fever / Y N
Anorexia / Y N / Epilepsy/Seizures / Y N / Measles / Y N / Scarlet Fever / Y N
Appendicitis / Y N / Fibromyalgia / Y N / Meningitis / Y N / Stroke / Y N
Arthritis / Y N / Glaucoma / Y N / Migraine Headache / Y N / Syphilus / Y N
Asthma / Y N / Goiter / Y N / Mitral Valve Prolapse / Y N / Suicide Attempt / Y N
Bleeding Disorders / Y N / Gonorrhea / Y N / CHF / Y N / Thyroid Problems / Y N
Bronchitis / Y N / Gout / Y N / Mononucleosis / Y N / Tonsillitis / Y N
Bulimia / Y N / Heart Disease / Y N / Multiple Sclerosis / Y N / Tuberculosis / Y N
Cancer / Y N / Hepatitis / Y N / Mumps / Y N / Typhoid Fever / Y N
Cataracts / Y N / Hernia / Y N / Pacemaker / Y N / Ulcers / Y N
Chronic Fatigue Syndrome / Y N / Herpes / Y N / Parkinsons Disease / Y N / Urinary Tract Infections / Y N
Chemical Dependency / Y N / High Blood Pressure / Y N / Pneumonia / Y N / Venereal Disease / Y N
High Cholesterol / Y N / Polio / Y N

PATIENT CONDITION

Reason for Visit/current problem?______

Using the symbols below, please draw in the location of your symptoms on the diagrams.

XXXX = Pain OOOO = Numbness/Tingling **** = Aching

BETTER / WORSE / NO CHANGE
Bending
Coughing/Sneezing
General Activity
Leaning on cart while walking
Lifting
Lying Down
Sitting
Standing
Strain
Walking

What position/activity makes your condition better or worse?

CIRCLE THE NUMBER INDICATING THE USUAL DEGREE OF PAIN

(0 means no pain, and 10 is the worst pain that you have ever felt in your life)

0 1 2 3 4 5 6 7 8 9 10

HEALTH HABITS OCCUPATIONAL

Circle Y or N if you use the substances below Circle Y or N if your work exposes you to the following:

& describe how much you use.

Y N / Caffeine / Y N / Stress / Y N / Hazardous Material
Y N / Tobacco / Y N / Heavy Lifting / Y N / Other
Y N / Recreational Drugs
Y N / Alcohol

Are you currently working? Yes No

If released from work:

By Whom?______When?______

Why?______

HEALTH HISTORY

Please indicate which DIAGNOSTIC TESTS you have had in evaluation of your main problem/complaint & date.

TEST / Y/N / DATE / TEST / Y/N / DATE
Plain X-Ray / EMG/NCT
Bone Scan / MRI
CT Scan / CT/Myelogram
Discogram / Other

Please mark which TREATMENTS you have had for your main problem and indicate whether they were helpful.

TREATMENT / X / RELIEF? / TREATMENT / X / RELIEF?
Trigger Point Injections / T.E.N.S. Unit
Epidural Steroid Injections / Manipulations
Physical Therapy / Traction
Electrical Stimulation / Aqua Therapy
Ultrasound / Whirlpool
Heat Packs / Acupuncture
Cold Packs / Other
Brace

Have you seen a Pain Management Specialist before – YES NO If yes, when?______

Have you taken any of these drugs previously?

DRUG / YES / NO / DRUG / YES / NO
Aleve (naproxyn) / Aspirin
Bextra / Arthrotec
Baclofen (lioresal) / Celebrex
Darvocet (propoxyphene) / Daypro
Demerol (Meperidine) / Dilaudid
Durgesic Patches (fentanyl) / Feldene (piroxicam)
Flexeril (cyclobenzaprine) / Ibuprofen (advil)
Lortab (hydrocodone) / Methadone
Motrin / MS Contin
MS IR (Morphine) / Etodolac (lodine)
Norco / Norflex
Oxycontin / Parafon Forte
Percodan / Percocet
Prednisone / Relafen
Robaxin (methocarbamol) / Skelaxin (metaxalone)
Soma (carisoprodol) / Talwin (pentazocine)
Toradol / Tylenol #3
Vicodin / Ultram (tramadol)
Ultracet (tramadol/APAP) / Zanaflex
Ketoprofen (orudis) / Roxicet

Hospitalizations/Surgeries

YEAR / Hospital Treating Physician / Reason for Hospitalization/Surgery & Outcome

Notes:

______