2014 Ashley Oaks Circle Wesley Chapel, Fl 33544 813.999.3030ph 813.333.0450fx Jose M. De La Torre, MD Today’s Date _______________________________ Social Security # ________-_______-_______ Patient Name ___________________________________________________________DOB ___________________ Gender: Male Female Address_______________________________________________________________________________________________________________ City ______________________________________________________ State ______________________Zip_____________________________ Home Phone # ____________________________ Cell # ________________________________ Other ________________________________ May we leave detailed messages at the above listed numbers? Yes No Race : Caucasian Ethnicity: American Language Spoken: English Black Cuban Spanish American Indian Asian Indian French Italian Asian Greek Hispanic Other ________________ Bosnian African American Other ___________________ Portuguese Chinese Japanese Other ________________ In Case of an Emergency please contact: Name _________________________________________________ Relationship _____________________ Phone # _______________________ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Primary Ins. Co ____________________________ Policy # ____________________________ Group # ____________________________ Policy Holder ______________________________ Relationship _________________________ DOB ______________________________ 2nd Ins. Co ________________________________ Policy # _____________________________ Group # ____________________________ Policy Holder ______________________________ Relationship __________________________ DOB _______________________________ Auto Related Injury? Auto Accident Carrier __________________________________________________________________________________________________ Claim # _______________________________ Adjuster Name & Phone # ____________________________________________________ Date of Accident ____________________________________________ State of Accident _____________________________________ Workers’ Compensation Related Injury? Workers’ Comp. Ins. Carrier ____________________________________________________________________________________________ Claim # _______________________________ Adjuster Name & Phone # ________________________________________________________ Date of Injury _______________________________ State of Injury ____________________________________________________________ 2014 Ashley Oaks Circle Wesley Chapel, Fl 33544 813.999.3030ph 813.333.0450fx Jose M. De La Torre, MD Primary Care Physician ___________________________________________________________Phone ________________________________ Pharmacy Name__________________________________________________________________Phone _______________________________ Pharmacy Location_____________________________________________________________________________________________________ INSTRUCTIONS: Please complete the following questionnaire before you see the doctor. Circle the answers that best describe your situation. You may select more than one answer per question. This information will help your doctor to more accurately understand your condition(s) and develop an appropriate plan of treatment. A copy of this form will be included in your medical record. PATIENT NAME: _________________________________________________________ DATE: _____________________ OCCUPATION: ___________________________ EMPLOYER: ___________________________________________________ WHOM MAY WE THANK FOR REFERRING YOU? ___________________________________________________________________ 1. CHIEF COMPLAINT: WHAT IS THE REASON FOR YOUR VISIT TODAY:____________________________________________________________ 2. AGE OF PATIENT: ___________ 3. WHAT ARE YOU BEING SEEN FOR? A. HEADACHE B. NECK PAIN C. UPPER BACK PAIN D. LOWER BACK PAIN E. ARM PAIN F. LEG PAIN G. OTHER: _________________ MALE FEMALE DO YOU HAVE ANY: A. WEAKNESS B. NUMBNESS C. TINGLING IF SO, WHERE? ______________________ IF MORE THAN ONE OF THE ABOVE IS CHOSEN, WHICH IS THE MOST PROBLEMATIC? _____________________________ MARK THE LOCATION(S) OF YOUR PAIN ON THE FIGURE(S) BELOW: 2014 Ashley Oaks Circle Wesley Chapel, Fl 33544 813.999.3030ph 813.333.0450fx Jose M. De La Torre, MD FOR SYMPTOMS OF PAIN FILL THE AFFECTED AREAS WITH THE FOLLOWING PATTERN: XXXXXXXX FOR SYMPTOMS OF NUMBNESS/TINGLING FILL THE AFFECTED AREAS WITH: OOOOOO PHYSICIAN NOTES: 4. WHICH TERM BEST DESCRIBES YOUR PAIN? CHARACTER/ Quality of pain: (Please check one box per line that describes your pain in words and severity) Sharp Stabbing Burning/ Hot Shooting Aching none none none none none mild mild mild mild mild moderate moderate moderate moderate moderate severe severe severe severe severe 5. RATE YOUR PAIN INTENSITY BY CIRCLING THE NUMBER THAT BEST DESCRIBES YOUR PAIN RIGHT NOW: NO PAIN 0 1 2 3 4 5 6 7 8 9 10 INTOLERABLE 6. WHEN DID THE PROBLEM(S) FIRST START OR WHEN DID THE INJURY OCCUR? __________________________________ 7. DID THE PROBLEM START AS A RESULT OF: A. NORMAL DAILY ACTIVITY B. MOTOR VEHICLE ACCIDENT C. SPORTS OR RECREATION D. FALL 8. E. F. G. H. JOB RELATED CANCER ILLNESS OTHER: _______________________________________ HAVE YOU SEEN A DOCTOR IN THE PAST MONTH FOR THIS CONDITION? YES NO IF YES, WHO/WHEN ________________________________________________________________________ 2014 Ashley Oaks Circle Wesley Chapel, Fl 33544 813.999.3030ph 813.333.0450fx Jose M. De La Torre, MD 9. HAVE YOU BEEN SEEN BY A PAIN MANAGEMENT DOCTOR BEFORE? YES NO IF YES, WHO/WHEN ________________________________________________________________________ 10. WHAT TREATMENT(S) HAVE YOU ALREADY RECEIVED FOR THIS CONDITION? (CIRCLE ALL THAT APPLY) A. MEDICATIONS (LIST IN TABLE BELOW) B. PHYSICAL THERAPY: HOW MANY WEEKS? ________ WAS IT EFFECTIVE? YES NO C. STEROID/CORTISONE/EPIDURAL INJECTIONS? (LIST IN TABLE ON NEXT PAGE) D. CHIROPRACTIC CARE: DR. _________________________ WAS IT EFFECTIVE? YES NO E. TENS UNIT: PRESCRIBED BY: _______________________ WAS IT EFFECTIVE? YES NO F. SURGERY TYPE: ___________________________ WHEN? ________________ DOCTOR? ___________________ TYPE: ___________________________ WHEN? ________________ DOCTOR? ___________________ TYPE: ___________________________ WHEN? ________________ DOCTOR? ___________________ 11. INJURY HISTORY (IF YOU HAVE NOT HAD ANY TYPE OF INJURY, CHECK BOX AND SKIP TO #12. ) A. HAVE YOU HAD ANY AUTO INJURIES? YES NO IF YES, WHEN? ____________________________ AUTO CASE IS: OPEN CLOSED B. HAVE YOU EVER HAD ANY SPORTS INJURIES? YES NO IF YES, WHEN? _____________________ C. HAVE YOU EVER BROKEN ANY BONES? YES NO IF YES, WHEN? _________WHAT BONE? ______________ D. HAVE YOU EVER HAD A WORKER’S COMPENSATION CLAIM? YES NO WORK COMP CASE IS: (CIRCLE ALL THAT APPLY): CURRENT PAST OPEN CLOSED SETTLED E. HAVE YOU EVER BEEN DISABLED? YES NO ARE YOU CURRENTLY DISABLED? YES NO IF YES, WHAT TYPE? SSD SSI 12. SINCE THE PAIN/CONDITION BEGAN, IT: A. B. C. D. HAS IMPROVED HAS WORSENED HAS REMAINED THE SAME COMES & GOES (FLUCTUATES) 13. WHAT AGGRAVATES THE PAIN? A. B. C. D. E. F. WHAT TIME OF DAY IS THE PAIN MOST INTENSE? WALKING H. COUGING STANDING I. TEMPERATURE SITTING OTHER: _____________ LYING DOWN BENDING ACTIVITY IN GENERAL A. B. C. D. WHEN GETTING UP IN THE MORNING DURING THE DAYTIME AT THE END OF THE DAY BEFORE BEDTIME DURING THE NIGHT WHAT MAKES THE PAIN BETTER? A. B. C. D. E. F. WALKING STANDING SITTING LYING DOWN RESTING MEDICATION 14. DOES THE PAIN AWAKEN YOU FROM SLEEP? A. NEVER B. OCCASIONALLY C. FREQUENTLY 15. DO YOU HAVE ANY DIFFICULTY WALKING DUE TO THIS CONDITION? A. YES B. NO 16. HAVE YOU HAD ANY PROBLEMS WITH BOWEL, BLADDER, OR SEXUAL FUNCTIONS SINCE THIS CONDITION BEGAN? A. NO B. YES, EXPLAIN: ______________________________________________________________________ 2014 Ashley Oaks Circle Wesley Chapel, Fl 33544 813.999.3030ph 813.333.0450fx Jose M. De La Torre, MD 17. HAVE YOU HAD A PREVIOUS PAIN PROBLEM/CONDITION? A. NO B. YES, EXPLAIN:______________________________________________________________________ REVIEW OF SYSTEMS: HAVE YOU RECENTLY EXPERIENCED ANY OF THE FOLLOWING? (MARK YES OR NO FOR EACH EYE, EAR, NOSE, THROAT GENERAL Y N CARDIOVASCULAR Y N Y N EYE PROBLEMS DOUBLE VISIONS HAY FEVER LOSS OF HEARING FEVERS CHILLS NIGHT SWEATS MALAISE DIZZINESS WEIGHT GAIN WEIGHT LOSS LOSS OF SLEEP MUSCLE/BONE/JOINTS Y N MUSCLE SPASM(S) NECK PAIN ARM PAIN BACK PAIN LEG PAIN JOINT PAIN PELVIC PAIN GASTROINTESTINAL Y N CHEST PAIN CONSTIPATION BLOATING DIARRHEA RECTAL BLEEDING HIGH BLOOD PRESSURE RAPID HEARTBEAT SWELLING OF ANKLES POOR EXERCISE ABILITY SNORING SINUS PROBLEMS EARACHE GENITO-URINARY Y N BLOOD IN URINE FREQUENT URINATION INCONTINENCE PAINFUL URINATION STOMACH BLEEDING SKIN STOMACH PAIN CANCER DISEASE NAUSEA/VOMITING HEARTBURN NEUROLOGICAL Y N HEMATOLOGICAL Y N NERVE DAMAGE SEIZURES (ACTIVE) NUMBNESS/TINGLING LIGHTHEADEDNESS MUSCLE WEAKNESS CANCER PROSTATE/COLON BREAST PERSISTENT COUGH COUGHING BLOOD SUICIDAL IDEATION BLEEDING PROBLEMS BLEEDING GUMS ADDICTION NERVOUSNESS CHRONIC BRONCHITIS SLEEP APNEA USE OXYGEN USE CPAP ENDOCRINE AGGRENOX PRADAXA OTHER ______ LUNG OTHER ________ RESPIRATORY Y N FEELING SAD/UNHAPPY BLOOD DISORDER DO YOU TAKE: COUMADIN LOVENOX PLAVIX HEPARIN POOR CONCENTRATION PSYCHIATRIC Y N SEVERE THIRST SHORTNESS OF BREATH SEVERE FATIGUE TAKE CORTISONE ALLERGY/IMMUNOLOGY ROUGH SKIN/ELBOWS DECREASED SEX DRIVE SHELLFISH ALLERGY LOSS OF SEXUAL PERFORMANCE HIV ENVIRONMENTAL ALLERGIES 18. PAST SURGICAL HISTORY HAVE YOU HAD ANY SURGERIES? (INCLUDE PRIOR PAIN INECTIONS) A. NONE DATE B. IF YES (LIST BELOW) SURGERY PHYSICIAN 19.PAST MEDICAL HISTORY DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING MEDICAL CONDITIONS? (CIRCLE ALL THAT APPLY) A. B. C. D. E. F. G. H. I. NONE THYROID DISORDER OVERWEIGHT LUNG DISEASE (COPD / EMPHYSEMA) ASTHMA/TUBERCULOSIS CORONARY ARTERY DISEASE (CHEST PAIN/ANGINA) PRIOR HEART ATTACK if yes WHEN? _____________ HIGH BLOOD PRESSURE / HYPERTENSION HEART DISEASE (CONGESTIVE HEART FAILURE) J. HIGH CHOLESTEROL K. PERIPHERAL VASCULAR DISEASE L. STOMACH ULCERS M. DIABETES MELLITUS N. HEPATITIS, TYPE: ______ O. LIVER DISEASE P. KIDNEY DISEASE Q. IMMUNE DISORDER R. SEIZURE DISORDER S. MULTIPLE SCLEROSIS/ OR OTHER BRAIN DISEASE T. STROKE / CVA U. OSTEOARTHRITIS/ OSTEOPOROSIS V. RHEUMATOID ARTHRITIS W. ENDOMETRIOSIS/ OR PELVIC PAIN X. DEPRESSION/ ANXIETY DISORDER Y. MENTAL DISORDER(S)/ ______________________ Z. CANCER/TUMOR, TYPE: ______________________ *** LIST ALL OTHER: ___________________________ Jose M. De La Torre, MD 2014 Ashley Oaks Circle Wesley Chapel, Fl 33544 813.999.3030ph 813.333.0450fx ALLERGIES 20. ARE YOU ALLERGIC TO ANY MEDICATIONS: ____ A. NO KNOWN ALLERGIES ____B. YES (LIST BELOW) MEDICATION REACTION (I.E. RASH, ETC) CURRENT MEDICATIONS 21. ARE YOU CURRENTLY TAKING ANY MEDICATIONS: __A. NONE __B. IF YES (LIST ALL BELOW) MEDICATION DOSAGE/FREQUENCY PRESCRIBING PHYSICIAN FOR WHICH CONDITION? SOCIAL HISTORY 22. PLEASE ANSWER THE FOLLOWING ABOUT YOURSELF: A. MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED B. WHO DO YOU LIVE WITH? ______________________________________________________________ C. YOUR HIGHEST LEVEL OF EDUCATION: SOME HIGH SCHOOL HIGH SCHOOL TRADE SCHOOL COLLEGE D. DO YOU CURRENTLY WORK? NO YES: OCCUPATION ______________________ EMPLOYER: ________________ E. HOW MUCH ALCOHOL DO YOU CONSUME: NONE SOCIAL DRINKER DRINK DAILY RECOVERING ALCOHOLIC F. DO YOU SMOKE? NO YES, I CURRENTLY SMOKE: ______# OF PACKS DAILY I QUIT SMOKING ___YRS AGO Have you been counseled about smoking cessation: NO YES G. DO YOU HAVE A HISTORY OF USE/ABUSE OF ILLICIT DRUGS? NO YES: LIST: _______________________________ H. Have you ever taken a pill from a family member or from a friend? NO YES FAMILY HISTORY 23. DO YOU HAVE A FAMILY HISTORY OF ANY OF THE FOLLOWING? (CIRCLE ALL THAT APPLY) A. NONE E. HEART DISEASE I. OSTEOARTHRITIS B. BACK/NECK PROBLEMS F. HYPERTENSION J. RHEUMATOID ARTHRITIS C. CANCER G. STROKE K. BLEEDING DISORDERS D. DIABETES H. ASTHMA L. LIST ALL OTHER: ________________________ Jose M. De La Torre, MD 2014 Ashley Oaks Circle Wesley Chapel, Fl 33544 813.999.3030ph 813.333.0450fx 24. PLEASE LIST THE NAMES OF ALL OF YOUR CURRENT PHYSICIANS: PHYSICIAN SPECIALTY CERTIFICATION TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS COMPLETE AND CORRECT. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM MY DOCTOR IF I, OR MY MINOR CHILD, EVER HAVE A CHANGE IN HEALTH INFORMATION. I UNDERSTAND THAT I AM RESPONSIBLE FOR MY BILL AND AGREE TO PAY ALL CHARGES FOR SERVICES AND ITEMS PROVIDED TO ME. I PERMIT A COPY OF THIS TO BE USED IN PLACE OF THE ORIGINAL. __________________________________________________________________________ SIGNATURE OF BENEFICIARY, GUARDIAN, OR PERSONAL REPRESENTATIVE _________________________ DATE __________________________________________________________________________ PLEASE PRINT NAME OF PATIENT, PARENT, OR GUARDIAN _________________________ RELATIONSHIP