AFCN-PHYSICAL MEDICINE
A Member of Arkansas Family Care Network, P.A.
Patient Information and Medical History
If you have a problem with vision, hearing, speech, or communication please let our
front desk personnel know.
Payment is expected at the time of service unless prior arrangements have been made. A copy of your
insurance card will be obtained for our records.
PATIENT INFORMATION
First Name_________________________ M.I.__________ Last Name___________________________
Address_______________________________________________________________________________
City________________________________________ State____________ ZIP_____________________
Telephone Home___________________ Work____________________ Cell ______________________
DOB ______________________________________Sex __________ SSN_________________________
E-Mail: ____________________________________________
Patient Marital Status: S M W D
RESPONSIBLE PARTY INFORMATION (You can leave this blank if same as patient)
First Name_________________________ M.I.__________ Last Name___________________________
Address_______________________________________________________________________________
City________________________________________ State____________ ZIP_____________________
Telephone Home___________________ Work____________________ Cell ______________________
DOB_______________ SSN_________________ Employer____________________________________
Relationship between patient and policy holder (circle one):
self
spouse
parent/guardian
INSURANCE INFORMATION (If we make a copy of your insurance care you can leave this
information blank)
Primary Insurance Co______________________________________ Effective Date________________
Address__________________________________________________ Telephone___________________
City_____________________________________________________ State_________ Zip____________
Group#______________________________________ Policy ID/#_______________________________
Women’s Health 1
Who referred you to our clinic ___________________________________________________________
What is your job or occupation __________________________________________________________
What does your work involve ____________________________________________________________
______________________________________________________________________________________
Leisure/Athletic Activities:
_______________________________________________________________
______________________________________________________________________________________
To ensure you receive a complete and thorough examination, please provide the following background
information. If you do not understand a question leave it blank and your provider will assist you. Thank
you.
Please check (√) any of the following whose care you are currently under or have recently seen:
_____Medical Doctor
_____Psychiatrist/Psychologist
_____Dentist
_____Physical Therapist
_____Chiropractor
_____Doctor of Oriental Medicine (acupuncture)
_____Other: ___________________________________________________________________________
______________________________________________________________________________________
If you have seen any of the above in the past 3 months, please describe for what reason (illness,
medical condition, physical, ect.): _________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
When was the date of your last complete physical (wellness) examination? _______________________
Is there any information from your last physical examination that you think I should know about? If
not you can leave blank.
______________________________________________________________________________________
______________________________________________________________________________________
The following are questions to gather some information about why you are coming to our clinic. If you
do not know the answer it is fine to leave it blank; we can talk about it during the interview.
Please briefly describe the problem that you would like for us to look at today._________________
______________________________________________________________________________________
______________________________________________________________________________________
Women’s Health 2
When and how did you start having this problem? __________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Is this problem getting worse, better, or staying about the same? _______________________________
Is the problem constant or tend to come and go? ____________________________________________
What kind of activities makes your complaints worsen? _____________________________________
______________________________________________________________________________________
Is there any certain time of the day that your symptoms are worse? ____________________________
______________________________________________________________________________________
What have you noticed that makes your problem feel better? __________________________________
______________________________________________________________________________________
Have you ever had this problem before? ___________________________________________________
Did you have treatment or did it go away on its own? ________________________________________
Have you had treatment for this current problem and did it help? _____________________________
______________________________________________________________________________________
Have you had any type of tests for this problem and when were they performed? Test may include xrays, lab, MRI, CT scan, nerve tests, for example:___________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
FOR OFFICE USE ONLY
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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Women’s Health 3
OBSTETRIC & GYNECOLOGICAL HISTORY
Number of pregnancies
________
Did you have trouble healing after delivery?
Y
N
Number of vaginal deliveries
________
Do you have a history of sexual abuse or trauma?
Y
N
Number of cesarean deliveries
________
Are you having regular periods/menstrual cycles?
Y
N
Number of episiotomies
________
Do you have frequent urinary tract infections?
Y
N
Birth weight of largest baby
________
Date of last pap smear
________
TEST RESULTS (have you had any of the following tests done?)
Urodynamics test
Y
N
Results/date ____________________________________
Cytoscope
Y
N
Results/date ____________________________________
Urine test
Y
N
Results/date ____________________________________
Bowel test
Y
N
Results/date ____________________________________
Ultrasound
Y
N
Results/date ____________________________________
Cough/sneeze/laugh
Y
N
Have a strong urge to urinate
Y
N
Lift/exercise/dance/jump
Y
N
Hear running water
Y
N
On the way to the bathroom
Y
N
Other __________________
Y
N
Wet the bed
Y
N
Have a “falling out” feeling
Y
N
Have burning/pain with urination
Y
N
Have pain with a full bladder
Y
N
Difficulty starting a stream of urine Y
N
Have an urgency of urination
Strain to empty your bladder
Y
N
(strong urge to urinate)
Y
N
Feel unable to empty bladder fully Y
N
Y
N
BLADDER SYMPTOMS
Do you ever lose urine when you:
Do you:
Urinate more than 7 times a day
BOWEL SYMPTOMS
Do you:
Strain to have a bowel movement
Y
N
Leak/stain feces
Y
N
Include fiber in your diet
Y
N
Have diarrhea often
Y
N
Take laxatives/enema regularly
Y
N
Leak gas by accident
Y
N
Have pain with bowel movement
Y
N
Have a very strong urge to move your bowels Y
N
How often do you move your bowels: ___________per day/week.
Most common stool consistency:
____ liquid
____ soft
____ firm
____ pellets
____other ____________________
Women’s Health 4
PAIN
Do you have pain with:
Sexual intercourse
Y
N
Pelvic exam
Y
N
Tampon use
Y
N
Do you have back, leg, groin, abdominal pain? Y
N
NUMERICAL PAIN SCALE (skip if you have no pain)
1. Please rate your current level of pain on the following scale (circle one):
0
1
(no pain)
2
3
4
5
6
7
8
9
10
(worst pain)
8
9
10
(worst pain)
2. Please rate your worst level of pain on the following scale (circle one):
0
1
(no pain)
2
3
4
5
6
7
3. Please rate your best/lowest level of pain in the last 24 hours on the following scale (circle one):
0
1
(no pain)
2
3
4
5
6
7
8
9
10
(worst pain)
[Score: #1_____ + #2_____ + #3_____ = _____/ 3 = __________ (Low Intensity = <5; High Intensity = >5)]
Do you have pain or symptoms anywhere else?
Yes
No
If yes where is it located and how would you describe it. ______________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Women’s Health 5
MEDICAL HISTORY
The next questions relate to any illnesses that you, your parents, are a sibling might have had. If you do
not know the answer just leave it blank. Some of the questions are not applicable (N/A) so just leave
them blank.
Have you had or do you
currently have any of the
following conditions (Circle
one)
Has any immediate family
member ever had any of the
following conditions (Circle
one)
Cancer? ---------------------------------------------Yes
No
If yes what kind of cancer? __________________________
Yes
No
_____________________
Diabetes? ---------------------------------------- Yes
High blood pressure? ------------------------- Yes
Heart disease/attack? ------------------------- Yes
If yes, date? ____________________
No
No
No
Yes
Yes
Yes
No
No
No
Angina/chest pain? ---------------------------- Yes
Stroke? ------------------------------------------- Yes
High Cholesterol? ----------------------------- Yes
Osteoporosis? ---------------------------------- Yes
Osteoarthritis? --------------------------------- Yes
Rheumatoid Arthritis? ----------------------- Yes
Lupus? ------------------------------------------- Yes
Thyroid problems? ---------------------------- Yes
Hepatitis/liver disease? ----------------------- Yes
Kidney Disease? ------------------------------- Yes
Asthma? ----------------------------------------- Yes
Migraine Headaches? ------------------------ Yes
Depression? ------------------------------------ Yes
Anxiety/panic attacks? ---------------------- Yes
Psoriasis? --------------------------------------- Yes
Tuberculosis? ---------------------------------- Yes
Multiple Sclerosis? ---------------------------- Yes
Parkinson’s Disease? ------------------------- Yes
Fibromyalgia? --------------------------------- Yes
HIV? --------------------------------------------- Yes
Sexually transmitted disease? -------------- Yes
Rheumatic fever? ----------------------------- Yes
Seizures? ---------------------------------------- Yes
Organ Transplant? --------------------------- Yes
Endometriosis? -------------------------------- Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Are you currently pregnant?........................................................Yes……….No
Is there a possibility you could be pregnant?..............................Yes…….....No
History of endometriosis?..............................................................Yes……….No
Do you use oral contraceptives?....................................................Yes…….…No
Are you post-menopausal?.............................................................Yes……….No
Do use hormone replacement therapy?........................................Yes……….No
Do you ever have episodes of severe fatigue or weakness?.........Yes……….No
Women’s Health 6
Do you have any allergies? Yes……No
If so, what are you allergic to?____________________________________________________________
____________________________________________________________________________________
Are you allergic to Latex?
Yes……No
Do you take blood thinners? Yes……No
Do you have a pacemaker or other type of implants, including joint replacement? _______________
_____________________________________________________________________________________
HOSPITALIZATION
Have you been hospitalized in the last 3 months? Yes
No
If yes, what for? _____________________________________________________________________________
If you have had any surgeries in the past, please describe them and the approximate date they occurred:
___________________________________________________________________________________________
___________________________________________________________________________________________
In the past 3 months have you had or are you currently
experiencing:
Trouble sleeping? …………………………………………… Yes……….No
Nausea/vomiting? …………………………………………… Yes……….No
Fever/chills/sweats? ………………………………………… Yes……….No
Unexplained weight loss or gain? …………………………. Yes……….No
Numbness/tingling? ………………………………………… Yes……….No
Weakness? ………………………………………………….. Yes……….No
Changes in appetite? ……………………………………….. Yes……….No
Difficulty swallowing? ………………………………………. Yes……….No
Changes in bowel or bladder function? …………………… Yes……….No
Blood in stool? ………………………………………………. Yes……….No
Dizziness? ……………………………………………………. Yes……….No
Shortness of breath? ………………………………………… Yes……….No
Insomnia? ……………………………………………………. Yes……….No
Upper respiratory infection? ………………………………. Yes……….No
Urinary tract infection? ……………………………………. Yes……….No
Changes in finger nails? ……………………………………. Yes……….No
Do you currently smoke or use tobacco products? ……………Yes………No
How many packs/pouches you use per day? __________
How many years have you used tobacco? ___________
Do you drink alcoholic beverages? ……………………….…….Yes….…...No
If yes, how many drinks per week? _____________________________
Women’s Health 7
List your current medications both prescription and over the counter (pills, injections, patches,
ointments, vitamins, or herbs):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Are you having any other symptoms of any kind anywhere else in your body? ___________________
______________________________________________________________________________________
______________________________________________________________________________________
FOR OFFICE USE ONLY
Vitals
Blood Pressure: _____/_____
Position: Sitting Standing
Extremity: Right Left
Tympanic Temperature: _____________
Resting Pulse Rate: __________________
Signature of provider: _______________________________________________ Date: ______________
Teresa Sharps PT LMT
Women’s Health 8
Arkansas Family Care Network
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
By signing below, I acknowledge that I have received a copy of the AFCN’s Policy of Privacy
Practices. The Notice describes how my health information may be used or disclosed. I understand
that I should read it carefully. I am aware that the notice may be changed at any time and that I
may obtain a revised copy of the Notice at the clinic location where I received heath care services.
Please furnish a copy of any conservator/guardianship papers with this form
All services rendered are the financial responsibility of the patient and not the insurance company.
Our office will bill your insurance company as a courtesy. Your financial responsibility is to ensure
that the Arkansas Family Care Network is paid for services rendered. This includes liability covered
injuries, as bills will not be postponed in anticipation of legal settlement. Information will be
provided to you to file your own insurance and supplied to your attorney upon your request.
I hereby authorize the healthcare providers of AFCN-Physical Medicine to furnish information to
insurance carriers concerning my illness and treatments and I hereby assign to the provider all
payments for medical services rendered to my dependents or myself. I understand that this
authorization will remain in effect as long as my dependents or I remain a patient.
I, _____________________________________________________, hereby consent to allow the
following person(s) access to information on my account that would otherwise be considered
protected health information: ____________________________________________________________
I acknowledge that I fully understand the above statements and that all provided information
relative to my health is accurate to the best of my knowledge.
Signature of patient or guardian: ______________________________________Date: ______________
4200 N. RODNEY PARHAM, SUITE 102
LITTLE ROCK, AR 72212
(501) 6610336
(501) 6610412
Women’s Health 9