Firststateortho.com

INTAKE FORM
□Dr.Axe □Dr.Bodenstab □Dr.Brady □Dr.Crain □Dr.Ginsberg □Dr.Handling □Dr.Hershey □Dr.Johnson □Dr.Kahlon □Dr.Katz
□Dr.Leitman □Dr.Moran □ Dr. Newell □Dr.Pushkarewicz □Dr.Raisis □Dr.Rudin □Dr.Sowa □Dr.Steele □Dr.Straight □Dr. Zaslavsky
PATIENT INFORMATION
Date: __________ Name: ______________________________________ Age: ________ FSO MR #: ________________
REASON FOR VISIT - Ort Home
Body Part(s): ___________________________________________________________________________________ □ RightLeftBilateral
Complaint: □ Pain □ Injury □ Fracture □ Numbness □ Swelling □ Other: _____________________________________________________________
HISTORY OF PRESENT INJURY - HPI: This Chief Complaint
Have you been off work for this problem?: □ Yes □ No Dates off work: __________________________________________________________________
Doctors who have treated you for this problem: __________________________________ Did that doctor refer you here?: □ Yes □ No
Diagnostic tests and treatment performed (please list when/where/what) : □ X-Ray _______________________ □ MRI ________________________________
□ Injection _________________ □ Surgery: _________________ □ NSAIDS (anti-inflammatories) _________________ □ EMG _______________________ □ CT/Scan _______________ □ Bone Scan _______________ □ Lab Work _______________ □ Other: _______________ □ PT ______________________ Have you ever had similar problems? If yes, please give details: __________________________________________________________________________
Onset/Date of Injury: __________________
Context: □ No Injury □ Injury □ Sports Injury □ MVA - Details:____________________________________
Severity:
Frequency:
Quality:
Radiation:
Radiates To: _______________
Aggravated By:
Relieved By:
Associated Symptoms / Pertinent Negatives:
Hand Dominance:
REVIEW OF SYSTEMS - Add Additional ROS
Do you have any of the following symptoms? (Please check all that apply) Constitutional:
Metabolic/Endocrine:
Neurological:
Immunological:
Hematologic/Blood:
Cardiovascular:
Respitory:
□ Cyanosis (blue coloration of skin) Gastrointestinal:
Integumetary/Skin:
Genitourinary:
PATIENT'S MEDICAL CONDITION - Assistant Doc>Vital Signs
Height: ___ft ___in Weight: _____lbs Blood Pressure:_____/_____ List details of any diet program: ____________________________
My weight in the last 6 months has: Not Changed Increased _____lbs. Decreased _____lbs.
Have you ever taken any anti-inflammatories/arthritis medications?: □Yes □No (Ex: Naprosyn/Ibuprofen) If yes, please list: _______________________
ALLERGIES - Assistant Doc>Add Allergy
(Please check all in which you have an allergy and list the reaction - hives, nausea, anaphylaxis, etc) Reaction:
Reaction:
Allergy & Reaction:
(anti-inflammatories - ibuprofen, naprosyn) □ No Known Drug Allergies
PATIENT'S MEDICAL HISTORY - Histories>Additional History
□ Degenerative Joint Disease □ Inflammatory Bowel Disease □ Juvenile Rheumatoid Arthritis □ Renal Disease PATIENT'S SURGICAL HISTORY - Histories>Additional History
□ Small Bowel Resection ______________________ Gender Specific
_________________________ (gallbladder removal) □ Neck Surgery - Details: □ Cesarean Section PATIENT'S FAMILY HISTORY - Histories> Additional Family History
Is your Father Living? □ Yes □ No If no, age deceased ________ cause of death ______________________________
Is your Mother Living? □ Yes □ No If no, age deceased ________ cause of death _______________________________
Are any of your brothers/sisters deceased? □ Yes □ No If yes, age deceased _______ cause of death ______________________________
Family history of chronic/inherited diseases: ________________________________________________________________________________
PATIENT'S SOCIAL HISTORY - Histories>Social History
Tobacco Use: □ Yes □ No □ Former/Year Quit _______
Consume Alcohol: □ Yes □ No □ Former/Year Quit _______
Activity Level: □ Sedentary □ Moderate □ Vigorous
Type of Exercise: _________________________ _______________________
SIGNATURE
Date: __________________ Signature of Patient, Parent or Guardian: ______________________________________________________________

Source: http://www.firststateortho.com/pdf/FSO-Patient-History-Form.pdf

Whs observational 9 (18916 - activated, traditional)

HEALTH STUDY PLEASE USE A BALL-POINT PEN WHEN COMPLETING THIS QUESTIONNAIRE. IT IMPROVES THE QUALITY OF OUR DATA. 1. Birth date: Last 6 digits of SSN: (optional) 2. WITHIN THE PAST 2 YEARS, have you been NEWLY DIAGNOSED with any of the following illnesses or had any of the following procedures? Please answer NO or YES on each line. IF YES, indicate the date (month/year) of the d

Microsoft word - questionnaire energetica natura

QUESTIONNAIRE D’EVALUATION NUTRITIONNELLE ……………………………………………………………. Date : ……/……/……. Date de naissance : ………………………………. Sexe : ………………. Veuillez indiquer ci-dessous 5 soucis majeurs de santé par ordre d’importance : 1. …………………………………………………………

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