Today’s Date:
PATIENT INFORMATION
Patient Name:
Sex:
Marital Status:
Date of Birth:
Age:
Social Security Number:
Employer:
Occupation:
Home Phone: _____________________ Cell Phone: _____________________ Work Phone:
Email address:
REASON FOR APPOINTMENT?
Is this injury related to: (Circle one) Work
Auto Accident
Sports
Other
Date symptoms began or accident happened?
Accident details:
***If this is a work related injury, please fill out the work comp information in addition to personal
insurance information listed below.***
INSURANCE INFORMATION
Primary Insurance:
Cardholder’s Name:
Relationship to Patient:
Cardholder’s Date of Birth:
Cardholder’s Social Security Number:
Secondary Insurance:
Cardholder’s Name:
Relationship to Patient:
Cardholder’s Date of Birth:
Cardholder’s Social Security Number:
WORK COMP INFORMATION
Have you reported this injury at work?
How did the injury occur?
□ Yes
□ No
Contact Person for Employer:
Work Comp Insurance Company:
Adjuster:
Claim #: _____________________________________________DOI:
Phone:
Adjustor Phone:
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CONTACT INFORMATION
Emergency Contact Person:
Home Phone:
Relationship:
Cell Phone:
Who may we release medical information to?
1.
Relationship:
2.
Relationship:
3.
Relationship:
Phone Number:
Phone Number:
Phone Number:
May we leave medical information on an answering machine or voicemail?
(Please Circle)
Work
Home
Cell Phone
How did you hear about us? (Please check all that apply.)
□ Friend/Relative
□Physician
□ER
□ Radio
□ Internet
□ Phone Book
□ Website
□ ZocDoc
□ Yes
□ No
□ Newspaper
□ Other:
Primay Care Physician:
Phone Number:
Referring Physician:
Phone Number:
Preferred Pharmacy: _______________________________________ Phone Number:
May we share information with: Primary Care Physician?
May we share information with: Referring Physician?
□ Yes
□ Yes
□ No
□ No
IF PATIENT IS A MINOR OR STUDENT UNDER THE AGE OF 18
Father’s Name:
Address:
Phone:
Social Security Number:
Date of Birth:
Mother’s Name:
Address:
Phone:
Social Security Number:
Date of Birth:
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HISTORY OF PRESENT ILLNESS
Where is your pain located? (i.e. wrist, ankle, low back)
Which is your dominant hand?
□ Right
□ Left
□ Right
□ Left
□ Ambidextrous
Approximate date of the onset of the problem:
How did the problem occur?
Any previous problems to this area? □ Yes □ No If yes, describe:
Who have you seen for this problem?
(Emergency room, family physician, etc.)
List past tests or treatments:
Intensity of pain (circle one): None 1
(X-ray, MRI, splint, surgery, medicine, physical therapy, etc.)
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Timing of pain/problem:
(When symptoms occur; example: after exercise/activities, rest, etc.)
Duration of pain/problem:
(How long have you had symptoms/pain? How long does it last?)
Type of pain: □ Burning
□ Aching
Does the pain radiate? □ Yes
□ No
□ Stabbing
□ Sharp
□ Shooting
□ Deep
□Other
If yes, to where?
What makes the pain better?
What makes the pain worse?
Is the pain: □ Constant
Any swelling: □Yes □No
□ Intermittent
Is it getting: □ Better
□Worse
□Staying the same
When do you notice it?
Do you note any weakness? □Yes
□No Where?
Do you note any numbness, tingling? □Yes □No Where?
Is it: □Constant
□Intermittent What causes it?
Have you ever had any problems in the past with this extremity (any type)? □Yes □No
What problems?
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PATIENT HISTORY FORM
I have no know allergies (Check if no) □
Please describe the ALLERGY and the REACTION (rash, hives, breathing problems) below.
Allergy
Reaction Allergy
Reaction Allergy
Reaction
I am not taking any medication at this time (Check if no) □
Please list medications below (include prescribed medications, birth control, herbals, vitamins, etc.)
Please indicate the MEDICATION NAME and DOSE below.
Medication
Dose
Medication
Dose Medication
Dose
Your Current Health Conditions
Mark if you have been diagnosed with any of the following, even if the condition is controlled by medication.
EENT
Gastrointestinal
Neurological
Asthma
□ Kidney disease
□ Anxiety
□
Chronic cough
□ Kidney stones
□ Depression
□
Shortness of breath
□ Pain with urinating
□ Rapid weight loss
□
Emphysema
□ Blood in urine
□ Endocrine
Chronic bronchitis
□ Frequent urination
□ Diabetes/High blood sugar
□
Sleep apnea
□ Prostate problems
□ Thyroid
□
Hematologic/Lymphatic/Immunologic
Cardiovascular
Integumentary
Heart attack
□ Skin disease
□ Anemia/low blood cells
□
Irregular heart beat
□
Type: ________________
Bleeding disorder
□
Stroke
□ Musculoskeletal
Type: _______________________
Congestive heart failure
□ Joint pains
□ HIV/AIDS
□
Heart murmur
□ Swelling of joints
□ Hepatitis
□
Blood clot lung/leg
□ Muscle spasms
□ General Medicine
High blood pressure
□ Weakness
□ Frequent infections
□
High cholesterol
□ Arthritis
□ Are you pregnant?
□
Malignant hypertension
□ Osteoporosis
□ Other: _______________________
Gout
□ NONE OF THE MEDICAL PROBLEMS LISTED ABOVE APPLY
□
SURGERIES/FRACTURES: Please check appropriate boxes below and indicate side of surgery/fracture
SURGERIES
ORTHOPAEDIC SURGERIES
Cataract L and/or R
Tonsillectomy
Heart: Bypass/ Catheterization
Appendectomy
Gallbladder Removal
Other:
□
□
□
□
□
Vasectomy
Prostate
Hysterectomy
Hernia
Vascular
□
□
□
□
□
Joint Replacement
□ Left □ Right Year_________
Type: (circle) Shoulder Knee Hip
Arthroscopic Surgery
□ Left □ Right Year_________
Body Part:____________
Fractures Body Part:____________ □ Left □ Right Year______
Spine Circle: Neck Midback Lumbar Level________
Level___________ Year___________
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HEALTH HISTORY, CONTINUED
SOCIAL HISTORY
Tobacco
Do you smoke or chew tobacco? □ Yes □ No
# of years________ # Packs or Cans/day________
Alcohol
Do you drink alcohol? □ Yes □ No
# of alcoholic beverages consume/day__________
Substance Use
Have you ever had a substance abuse problem? □ Yes □ No
Specify the substance__________________
Do you use a substance currently? □ Yes □ No
Specify the substance__________________
FAMILY HISTORY
(Please check appropriate boxed below)
Condition
Family Member
Heart attack
□ _________________
High Blood Pressure
□ _________________
High Cholesterol
□ _________________
Tuberculosis
□ _________________
Liver Disease
□ _________________
Kidney Disease
□ _________________
Gout/Arthritis
□ _________________
Osteoporosis
□ _________________
Stroke
□ _________________
Asthma
□ _________________
What physical activities do you enjoy? Please circle
Hike Bike Golf Pilates Yoga Ski Snowboard
Run Jog Hockey Other___________________
What are your job/work requirements?
___________________________________________
___________________________________________
Vaccinations
Hepatitis A □
Hepatitis B □
Condition
Thyroid problems
Cancer
Alcohol abuse
Anxiety/Depression
Glaucoma
Hepatitis
HIV
Bleeding problems
Sickle Cell Anemia
Other
□
□ Type
□
□
□
□
□
□
□
Pneumovax □
Tetanus
□
Family Member
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
CERTIFICATION BY PATIENT OR RESPONSIBLE PARTY
I have reviewed the information which I have submitted and is contained in this New Patient Packet. I
certify that all information given is accurate and complete to the best of my knowledge.
Patient or Responsible Party’s Signature: ___________________________
Date: _______________
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