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

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

Example: Pain

Pain at its Worst

Pain at its Best
(lying down, resting)	0
	0
Pain on Average
Pain on Average

		0

SpineIntake.doc 3/20/04

Page 3

HISTORY OF PRESENT COMPLAINT

Age:

2.  Male

 Female

3.  Right Handed

 Left Handed

Where is your problem located?

 Left side  Right side

 Neck

 Upper Back

 Arm/Elbow

 Shoulder

 Wrist/Hand

 Lower Back

 Hip

 Leg

 Knee

 Ankle

 Foot

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

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

Question	Answer
Form Name	Emory Healthcare New Patient Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	emory patient form, emory new patient forms, emory neurology new patient forms, emory healthcare new patient

Emory Healthcare New Patient Form – Fill Out and Use This PDF

Emory Healthcare New Patient Form PDF Details

Form Preview Example

Emory Healthcare New Patient Form isn’t the one you’re looking for?

Emory Healthcare New Patient Form – Fill Out and Use This PDF

Emory Healthcare New Patient Form PDF Details

Form Preview Example

Emory Healthcare New Patient Form isn’t the one you’re looking for?

Related Documents