2701 E. Camelback Road #163

Sarah Quinn, FNP-C

Phoenix, Arizona 85016

P: 480.351.3688

F: 480.351.3689

Patient Intake Sheet

Patient Information:
Name: / Cell Phone: ( )
Address: / Work Phone: ( )
Emergency Phone: ( )
Email Address: / Date of Birth: Age:
Who referred you? / Weight: Height:
Who is your primary care physician? / Employer:
Today’s Date: / Your Occupation:
What is the medical reason that brought you to Arcadia Wellness Center?
Medications / Allergies
Past surgeries / Dates
Review of medical history (please mark all appropriate boxes)
General:
☐Fatigue
☐Cancer
☐Weakness
☐Tremors / ☐Low Sex Drive
☐Bruise easily
☐Diabetes
☐Other: ______/ ☐Insomnia
☐Fevers
☐Alcohol (Quantify_____)
Head, Eyes, Ears, Nose and
☐Eye problems
☐Ringing in ears
☐Hearing problems
☐Headaches / Throat:
☐Earaches
☐Sinus problems
☐Nose bleeds
☐Recurrent sore throats / ☐Dental problems
☐Thyroid problems
☐Head injury
☐Other: ______
Cardiovascular:
☐Chest pain
☐Poor circulation
☐Heart attack
☐Murmur
☐Stroke / ☐Irregular heartbeats
☐Swelling in feet
☐MVP
☐Phlebitis
☐Pacemaker / ☐Fainting
☐High blood pressure
☐Valve replacement
☐High cholesterol
☐Other: ______
Respiratory:
☐Wheezing
☐Asthma
☐Smoking (packs/day _____) / ☐Short of breath
☐Valley fever
☐Emphysema
☐Bronchitis / ☐Pneumonia
☐Cough
☐Tuberculosis
☐Other: ______
Gastrointestinal:
☐Nausea/vomiting
☐Acid reflux / ☐Abdominal. cramps
☐GI bleeding from meds / ☐Constipation
☐Other: ______
Musculoskeletal:
☐Neck pain
☐Joint pain
☐Osteoarthritis
☐Other: ______/ ☐Back pain muscle
☐Rheumatoid spasms
☐Joint injury arthritis / ☐Tennis elbow
☐Carpal tunnel syndrome
☐Bursitis
Renal:
☐Kidney infections
☐Hepatitis (Active?___) / ☐Kidney problems
☐Other: ______/ ☐Bladder infections
Neuropsychological:
☐Depression
☐Stress problems / ☐Anxiety
☐Seizure disorder / ☐Drug/alcohol abuse
☐Other: ______
Family history: Indicate which family member has the following medical problems
Disease:
Headaches
Heart disease
Stroke
Diabetes
High blood pressure
Increased cholesterol
Arthritis
Rheumatoid arthritis
Kidney problems
Liver problems
Seizures
Osteoporosis
Cancer
Other medical problems: / Which family member(s)?
______
______
______
______
______
______
______
______
______
______
______
______
______
______
What is your pain level today?
Mark on the line where your pain is today:

______Which number (0-10) describes your painright now?
______Which number (0-10) is your worst pain?
______Which number (0-10) is your least pain?
______Which number (0-10) describes your average pain over the past week?
Location of pain
Use this diagram to indicate the location and type of pain. Mark the drawing with the following letters that best indicate your symptoms:
“N” = numbness
“S” = stabbing pain
“B” = burning pain
“P” = pins and needles
“A” = aching pain
Details of your pain
How did your current episode begin: Suddenly ______Gradually ______
When did your current episode begin? ______
What caused your current pain episode? ______
Has the pain lessened, worsened, or stayed the same? ______
Is this a work-related injury? ______If yes, date of injury ______
Is this a motor vehicle injury? ______If yes, date of injury ______
What does the pain feel like?
Check all that apply to the quality
☐Throbbing
☐Shooting
☐Stabbing
☐Sharp
☐Cramping / of your pain.
☐ Gnawing
☐Hot-Burning
☐Aching
☐Heavy
☐Tender / ☐Splitting
☐Tiring/Exhausting
☐Sickening
☐Fearful
☐Punishing/Cruel
How does your pain change over time?
Check the word or words which
☐Continuous
☐Steady
☐Constant
☐Other details: ______/ best describe the pattern of
☐Rhythmic
☐Periodic
☐Intermittent / your pain.
☐Brief
☐Transient
☐Momentary
Mark the effect of each of the following on your pain:
Sitting
Standing
Rising from sitting
Bending forward
Bending backward
Walking
Climbing stairs
Lying on your back
Lying on your stomach
Driving
Coughing/sneezing
Lifting objects
Other factors / Increases my pain
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐ / Decreases my pain
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐ / No change in my pain
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Accident information:
If your injury/pain is the result of an accident or some other incident, please provide the following details:

Date of injury, location of injury, and treatment at time of injury
Describe how the injury occurred

Are there other details of your pain or medical conditions we should know about?

Authorizations and Releases

Acardia Wellness Center.2701 E. Camelback Rd, #163, Phoenix, AZ 85016

Ph. 480-351-3688, Fax. 480-351-3689

NAME DOB

Consent for Treatment

I, the undersigned, hereby authorize Sarah Quinn, FNP-C and whomever he/she may designate as his/her assistant(s) to perform diagnostic tests, and to administer treatment as necessary.

I, also certify that no guarantee or assurance has been made to the results that may be obtained and release all liability related to care.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. I permit this office to endorse remittances for the conveyance of credit to my account. HOWEVER, I CLEARLY UNDERSTAND AND AGREE THAT ALL SERVICES RENDERED TO ME ARE CHARGED DIRECTLY TO ME AND THAT I AM PERSONALLY RESPONSIBLE FOR PAYMENT.

Patient’s SignatureDate Witness

X-Ray/Medical Records Release

I have requested the release of records of (patient’s name) which are a part of the records at (facility)

I hereby request and authorize you, your employees and agents to furnish to the person(s) listed below or anyone designated in writing by them, all copies of records and reports, including copies of x-rays and photo static copies, abstracts or excerpts of all records and any other information they may request relating to any examination, treatment or opinion concerning any condition that I may have had in the past, now have, or may have in the future.

Please forward this to: Acardia Wellness Center. 2701 E. Camelback Rd., #163, Phoenix, AZ 85016 or fax records to 480-351-3689

Patient’s SignatureDate Witness

DOB:SSN:

Consent for Treatment of Minor

I hereby authorizeFNP-C and whomever he/she may designate as his/her assistant(s), to perform diagnostic tests, including but not limited to radiographs, and to administer treatment as he/she deems necessary to

my (indicate relationship of child) (child’s name)

Guardian’s SignatureDate Witness