Emory Healthcare New Patient Form PDF Details

When new patients first encounter the comprehensive and meticulously detailed New Patient Information form provided by Emory Healthcare, they embark on a vital step towards receiving personalized and efficient care. This form is ingeniously designed to gather a wide spectrum of personal and medical information, ensuring that all bases are covered -- from basic contact information and referral details to a precise history of the patient’s present complaints, social history, and past medical or surgical history. Patients are requested to provide a thorough account of their condition, including symptom descriptions, pain levels with a unique orthopedic pain chart, and the treatments they have undergone, which further aids in crafting a targeted care plan. Moreover, it encompasses inquiries about the patient’s social history, lifestyle factors such as smoking and alcohol consumption, and legal questions regarding lawsuits, which could all be relevant to the patient’s health journey. The form also meticulously collects data on past medical and surgical history, current medications, and allergies, ensuring that healthcare providers have a well-rounded view of the patient’s health. This thorough approach not only streamlines the process of integrating new patients into the Emory Healthcare system but also underscores the institution’s commitment to delivering personalized and comprehensive healthcare services.

QuestionAnswer
Form NameEmory Healthcare New Patient Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesemory patient form, emory new patient forms, emory neurology new patient forms, emory healthcare new patient

Form Preview Example

NEW PATIENT INFORMATION FORM

Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently.

Thank you for your cooperation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

Patient Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone: Home: (

)

 

 

 

 

Work: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How were you referred to The Emory Spine Center: Physician

Patient / Friend

Health Connection

 

 

 

 

Workers Comp

Emory Reputation Insurance

Radio / TV Advertisement

Other:

 

 

 

 

Referring Physician or Referral Source:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone: (

)

 

 

 

 

 

 

Fax: (

)

 

 

 

 

 

 

 

 

 

 

Do you want your medical records sent to this physician?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Doctor:

Address:

City:

Phone: (

)

 

 

Fax: (

)

 

Do you want your medical records sent to this physician?

Yes

No

Are there any other physicians to whom you would like your medical records sent? (Please include name and address)

(Continued on next page)

SpineIntake.doc 3/20/04

Page 2

ORTHO PAIN CHART

Mark the areas on your body where you feel the described sensations using the appropriate symbol from the list below. Please include all affected areas.

 

= = =

 

o o o

Burning

x x x

 

/ / / /

Numbness =

= = =

Pin & Needles =

o o o

Aching =

x x x

Stabbing =

/ / / /

 

= = =

 

o o o

 

x x x

 

/ / / /

RL LR

RL LR

Please indicate your current pain level by placing a line below with “0” = no pain and “10” = worst pain imaginable.

Example: Pain

0

Pain at its Worst

0

Pain at its Best

 

 

 

(lying down, resting)

 

0

 

 

Pain on Average

 

 

 

 

 

 

 

 

 

 

0

10

10

10

10

SpineIntake.doc 3/20/04

Page 3

HISTORY OF PRESENT COMPLAINT

1.

Age:

 

 

2. Male

 

Female

3. Right Handed

Left Handed

4.

Where is your problem located?

Left side Right side

 

 

 

 

 

 

 

 

 

 

Neck

Upper Back

Arm/Elbow

Shoulder

Wrist/Hand

 

 

 

 

 

 

 

Lower Back

Hip

Leg

Knee

Ankle

Foot

 

 

 

 

 

 

5.

How long have you had this problem?

 

 

 

Since?

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

month

 

 

day

 

year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Briefly, please give the details of how this problem originally started:

7.Was this from a work-related injury? No Yes Have you missed any work because of this problem?

- Is it under workers compensation No Yes No Yes, how much?

8.Please describe your present pain now (what you feel, where, when, etc.):

9.Of the following list of treatments, please indicate the effect of those which have been used in an attempt to help

your present problem: (Check one of each)

 

 

 

 

Which type

 

Helpful

No Help

Not Used

Antiinflammatory

 

 

Muscle Relaxants

 

 

Narcotic Pain Medications

 

 

Hot Packs

 

Ice

 

 

Ultrasound

 

 

Physical Therapy Treatment

 

 

Cortisone Injection

 

Trigger Point Injection

 

 

Brace/Splint

 

 

Chiropractor

 

 

Acupuncture

 

Other:

 

 

 

 

 

 

 

 

 

(Continued on next page)

 

 

 

 

SpineIntake.doc 3/20/04

Page 4

PAST HISTORY

10.

Please indicate whether you have had any of the following studies for this problem:

 

 

 

 

 

YES

NO

WHEN/WHERE

 

 

 

YES NO

 

 

WHEN/WHERE

 

 

 

Regular X-ray

 

 

 

CT Scan

 

 

 

 

 

 

 

 

 

EMG

 

 

 

MRI

 

 

 

 

 

 

 

 

11.

Have you had surgery for this problem in the past: (Check one) Yes No

 

How many times?

 

 

 

What was the date(s) of the most recent surgery?

 

 

,

 

 

,

 

 

 

 

 

 

 

 

 

Did you improve from the surgery procedure(s)?

Yes

No

 

 

 

 

 

 

 

12.

Have you had any past episodes of similar pain or injury?

Yes

No

(please describe)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL HISTORY

13.

Current work status: Working full duty

Working restricted duty (Since

)

Retired

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disabled

( Since

 

 

 

) Student

Homemaker

Unemployed

 

 

 

 

 

Company:

 

 

 

 

 

 

 

Occupation:

 

 

 

 

 

 

 

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How long have you worked for this company?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Marital status

Single

Married

Divorced

 

 

Widowed

 

 

 

 

 

 

15.

Number of Children:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.

I live:

Alone

 

With:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17.

I live in a:

House

 

Apartment

Assisted living

Nursing home

 

 

 

 

 

 

18.

Are you a cigarette smoker?

 

Yes, now Never Quit -

How long ago did you quit?

 

If you answered “yes” or “quit”, how much do or did you smoke per day?

 

 

 

 

 

 

 

 

 

 

 

Less than ½ pack

½ pack

¾ pack

1 pack

 

More (How many?)

 

How old were you when you started smoking?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

 

 

 

 

 

 

 

 

 

 

19.

Do you drink any alcoholic beverages?

(Check one)

 

 

 

 

 

 

 

 

 

 

 

 

 

0 to 3 drinks per month

 

1 to 2 drinks per day

 

 

3 to 5 drinks per day

 

 

 

 

 

 

 

More than 5 drinks per day.

How many?

 

/

Alcoholic in past?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

Have you ever had a problem with drug dependence?

Yes

 

No

 

 

 

 

 

 

21.

Are there any law suits pending or contemplated related to your problem?

Yes

No

 

 

 

 

If yes, please give your attorney’s name and phone number:

SpineIntake.doc 3/20/04

 

 

 

 

 

 

 

 

 

Page 5

 

 

 

 

 

 

 

 

 

MEDICAL/SURGICAL HISTORY

 

 

 

 

 

Please choose all current and past medical conditions

 

 

 

 

No medical problem

Diabetes

 

 

 

Bleeding disorders

High blood pressure

Thyroid disease

 

 

 

Anemia

Heart attack

Stomach ulcers / Gastric Reflux

Blood clots in legs/lung

Heart failure

Irritable bowel

 

 

 

Endometriosis

Abnormal heart rhythm

Stroke

 

 

 

Ovarian cysts

Lung disease

Seizures

 

 

 

Anxiety

Tuberculosis

Cancer – where?

 

 

 

 

Depression

Asthma

Kidney Failure

 

 

 

Schizophrenia

Bronchitis

Kidney Stones

 

 

 

Anorexia/bulemia

Emphysema

Osteoporosis

 

 

 

Alcoholism

Liver disease

Osteoarthritis

 

 

 

Seen a psychiatrist

Hepatitis

Rheumatoid arthritis

 

 

 

HIV

Are you under a doctor’s care for any other medical condition?

Yes

No

 

If yes, please explain

 

 

 

 

 

 

 

Please choose all surgeries you have had

 

 

 

 

Spine-Neck

Appendix / Intestine

 

 

 

Eyes

Spine-Lower back

Hernia / Colon / Rectum

 

 

Ears

Brain

Hysterectomy / C-section / Female

Nose

Heart / Pacemaker / IV Filter

Kidneys / Bladder / Urinary

 

 

Throat / Tonsils

Angioplasty / Stent

Prostate

 

 

 

Other

 

 

Lung

Shoulders / Arms / Hands

> Describe

 

 

 

 

 

Gallbladder / Stomach

Hips / Knees / Legs / Feet > Describe

 

 

 

 

 

 

 

 

 

 

 

List All Allergies

Substance

 

Reaction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List All Current Medications

Name

 

Dose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Continued on next page)

SpineIntake.doc 3/20/04

Page 6

FAMILY HISTORY

What illnesses run in your close family (other than yourself)?

Scoliosis

Diabetes

Kidney disease

Spine disease

Cancer

Other:

Arthritis

Bleeding disorder

 

 

 

Heart disease

Mental illness

 

 

 

High blood pressure

Alcoholism

 

 

 

REVIEW OF SYSTEMS

Please check off any current or recent problems you have

GENERAL

Unexplained weight loss

Appetite change

Fevers or chills

Night sweats

Marked fatigue

Difficulty sleeping

EAR, NOSE, THROAT

Difficulty swallowing

Hoarseness

Loss of hearing

Ear pain

Nosebleeds

Gum trouble

EYES

Glasses

Change of vision

CARDIOVASCULAR

Heart or chest pain

Abnormal heartbeat

Poor heart function

Ankle Swelling

LUNG

Morning cough

Shortness of breath

Productive cough or sputum

DIGESTIVE

Nausea or vomiting

Stomach pain or ulcers

Heartburn/acid stomach

Frequent diarrhea

Frequent constipation

Uncontrolled loss of stool

Blood in stool

Hemorrhoids

SKIN

Frequent rashes

Frequent itchiness

Easy bruising

Swollen ankles

NEUROLOGICAL

Seizures

Blackouts/fainting

Tremor

Headaches/migraines

MUSCULOSKELETAL

Joint Pains

Joint Swelling

Back Pain

Neck Pain

Muscle Aches

GENITOURINARY

Burning on urination

Difficulty starting urination

Incontinence

Pelvic pain

Urinate at night more than once

Unable to completely empty bladder

PSYCHIATRIC

Depression

Nervous exhaustion

Anxiety

Paranoia

Obsessive/compulsive behavior

SpineIntake.doc 3/20/04