Registration Form

 

PATIENT INFORMATION:
NAME:
DATE:
PHONE:
ADDRESS:
CITY:
STATE/ZIP:
DATE OF BIRTH:
AGE:
SOCIAL SECURITY #:
SEX: MALE FEMALE
MARITAL STATUS: MARRIED SINGLE OR OTHER:
 
EMPLOYER:
PHONE:
ADDRESS:
CITY:
STATE/ZIP:
ALLERGIES:
REFERRING DOCTOR:
FAMILY DOCTOR:
INJURED: HOW WERE YOU INJURED? WORK AUTO OTHER
DATE ONSET:
INSURANCE INFORMATION:
PRIMARY INS:
ID#:
GROUP:
SUBSCRIBER:
DOB:
SEX: MALE FEMALE
EMPLOYER/ADDRESS:
 
SECONDARY INS:
ID#:
GROUP:
SUBSCRIBER:
DOB:
SEX: MALE FEMALE
EMPLOYER/ADDRESS:
WORKER'S COMPENSATION CASES:
NAME OF EMPLOYER
WHERE INJURED:
ADDRESS:
NAME OF COMPENSATION CARRIER:
ADDRESS:
AUTO ACCIDENT CASES:
NAME OF CAR INSURANCE CARRIER:
ADDRESS:
MEDICAL PAYMENT COVERAGE:
NAME OF ATTORNEY:
ADDRESS:
INJURY HISTORY:
PATIENT'S NAME:
TODAY'S DATE:
CHIEF COMPLAINT
WHAT ARE YOU SEEING THE DOCTOR FOR TODAY:
   
CURRENT MEDICAL PROBLEM IS THE RESULT OF A(N):
(CHECK ALL THAT APPLY)		 CAR ACCIDENT WORK ACCIDENT
SPORTS INJURY ACCIDENT
OTHER:
   
THIS OCCURRED DURING:
(CHECK ALL THAT APPLY) 		LIFTING REACHING PULLING
HIT BY OBJECT PUSHING
TWISTING FALLING BENDING
SQUATTING NOT KNOWN
HISTORY OF PRESENT ILLNESS
PART OF THE BODY TO BE EVALUATED BY DOCTOR:
DESCRIBE YOUR SYMPTOMS:
 
PAIN LEVEL:
(RATE YOUR DISCOMFORT ON A SCALE OF 0-10, 10 BEING SEVERLY PAINFUL, AND 0 BEING NOT PAINFUL)
LOCATION:
   
QUALITY AND DURATION OF PAIN:
(CHECK ALL THAT APPLY)		 SHARP DULL THROBBING
BURNING ELECTRIC SHOCKS
"PINS & NEEDLES" TINGLING
CONSTANT INTERMITTENT (ON & OFF)
   
WHICH OF THE FOLLOWING ARE YOU FEELING?
STIFFNESS WHEN?
NUMBNESS WHEN?
SWELLING WHEN?
LOCKING WHEN?
CATCHING WHEN?
GIVING WAY WHEN?
WEAKNESS WHEN?
DIFFICULTY WALKING WHEN?
OTHER
       
   
HOW LONG HAS YOUR INJURY BEEN BOTHERING YOU? # DAYS
# WEEKS
# MONTHS
# YEARS
   
WHEN DO YOUR SYMPTOMS OCCUR?
(CHECK ALL THAT APPLY):
WALKING RUNNING AT NIGHT EXERCISING AT WORK AFTER WORK
RISING FROM A CHAIR GOING UP STAIRS GOING DOWN STAIRS
OTHER:
   
WHAT MAKES YOUR SYMPTOMS BETTER?
(CHECK ALL THAT APPLY):
REST HEAT ICE BRACE ACE WRAP EXERCISE MEDICATION
PHYSICAL THERAPY OTHER:
   
HAVE YOU HAD ANY OTHER TREATMENTS FOR THE PROBLEM YOU ARE SEEING THE DOCTOR FOR TODAY:
YES NO
IF YES, PLEASE DESCRIBE:
   
MEDICAL HISTORY REVIEW
GENERAL HEALTH MEDICATIONS
EXCELLENT
GOOD
FAIR
POOR 		TAKING NO MEDICATIONS
TAKING THE FOLLOWING MEDICATIONS:
   
ALLERGIES TO MEDICATIONS SOCIAL HISTORY
NO DRUG ALLERGIES
ALLERGIC TO PENICILLIN
ALLERGIC TO SULFA DRUGS
OTHER:
OTHER: 		ALCOHOL:
NONE LIGHT HEAVY
TOBACCO:
NONE LIGHT HEAVY
NUMBER OF CHILDREN:
   
FAMILY HEALTH HISTORY BLEEDING DISORDERS
NO HEALTH PROBLEMS
ANESTHESIA COMPLICATIONS
MALIGNANT HYPERTHERMIA
OTHER: 		NO PROBLEMS
ANEMIA
BLEEDING PROBLEM
OTHER:
   
METABOLIC DISORDER NEUROLOGIC
NO PROBLEMS
DIABETES
LOW BLOOD SUGAR
OTHER:

NO PROBLEMS
HEADACHES
SEIZURES
HEAD INJURY
DEPRESSION
DIZZINESS
STROKE: R SIDE L SIDE
NUMBNESS
OTHER:

   
EYES EARS
NO PROBLEMS
R L IMPAIRED VISION
R L CATARACT
GLASSES/CONTACTS
OTHER: 		NO PROBLEMS
R L IMPAIRED HEARING
R L HEARING AID
RINGING OR BUZZING
OTHER:
   
NOSE/THROAT LUNGS
NO PROBLEMS
BLEEDING
PERSISTENT HOARSENESS
SINUS PROBLEMS
DIFFICULT SWALLOWING
OTHER: 		NO PROBLEMS
ASTHMA
WHEEZING
COUGHING UP BLOOD
SHORTNESS OF BREATH
PAIN ON BREATHING
PROBLEM WITH ANESTHESIA
OTHER:
   
HEART GASTRO/INTESTINAL
NO PROBLEMS
CHEST PAIN
HISTORY OF HEART ATTACK
CORONARY ARTERY DISEASE
HIGH BLOOD PRESSURE
LEG/ANKLE SWELLING
IRREGULAR HEART BEAT
OTHER: 		NO PROBLEMS
ULCERS
REFLUX
CONSTIPATION
DIARRHEA
NAUSEA/VOMITING
CHANGE IN BOWEL HABITS
OTHER:
   
GYNECOLOGICAL URINARY SYSTEM
NO PROBLEMS
MENSTRUATION PROBLEMS
EXCESS BLEEDING
ABNORMAL BREAST EXAM
OTHER: 		NO PROBLEMS
PAINFUL URINATION
BLOODY URINE
FREQUENT URINATION
DIFFICULT URINATION
HISTORY OF KIDNEY STONES
OTHER:
   
CANCER HISTORY MY HEIGHT: FEET INCHES
NO PROBLEMS
LUNG CERVIX
LIVER OVARIAN
PROSTATE UTERUS
COLON BLADDER
SKIN BREAST
BONE KIDNEY
OTHER:
MY WEIGHT: POUNDS
   
PAST SURGERIES  
NO SURGERIES PERFORMED
  DATE
HEAD/BRAIN SURGERY
CATARACT SURGERY: ( R L)
NECK
THYROID
HEART SURGERY
LUNG SURGERY
BREAST SURGERY
GALL BLADDER REMOVAL
STOMACH/BOWEL SURGERY
KIDNEY STONES
APPENDIX REMOVAL
PROSTATE SURGERY
HYSTERECTOMY
HEMORRHOID SURGERY
VASCULAR SURGERY
OTHER:
   
MUSCULOSKELETAL SURGERIES
NO PAST SURGERIES PERFORMED
  DATE
SPINE SURGERY
SHOULDER SURGERY: ( R L)
ELBOW SURGERY: ( R L)
WRIST/HAND SURGERY: ( R L)
HIP SURGERY: ( R L)
KNEE SURGERY: ( R L)
ANKLE/FOOT SURGERY: ( R L)
OTHER:
   
Home | Who Are We? | What We Do | Why Choose Us? | Where Are We? | Pre/Post Op Guidelines | Insurance Coverage | FAQ's | Registration | Links | What's New?