NEW PATIENT MEDICAL HISTORY PACKET

NEW PATIENT MEDICAL HISTORY PACKET First Name:______________________________Last Name:___________________________________ Birth Date:_______________ G...
Author: Gerard Austin
2 downloads 2 Views 334KB Size
NEW PATIENT MEDICAL HISTORY PACKET First Name:______________________________Last Name:___________________________________ Birth Date:_______________ Gender:

Male

Female

Height:___________Weight____________

Primary Care Physician:_______________________ City, State:________________________________ Referring Physician:__________________________ City, State:________________________________ Current Pharmacy:________________________Street & City:_________________________________ Brief reason for visit:___________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

1. Allergies – Please list all medication or latex allergies. Allergy: Allergy: Allergy: Allergy: Allergy: Allergy:

Reaction: Reaction: Reaction: Reaction: Reaction: Reaction:

2. Past Medical History- Circle ANY of the problems YOU have had High Blood Pressure Measles/Mumps/Rubella Tuberculosis Muscle Disease Depression Constipation Thyroid Disease Taking Blood thinner

Diabetes Hypoglycemia Heart Disease Heart Attack Asthma Bronchitis/ Emphysema Stomach Ulcer Glaucoma Migraines/Headache Tissue Disease Seizure Stroke Cancer Arthritis Polio Prostate Problems Kidney Trouble Swelling of Joints Bleeding Disorder HIV/AIDS Hepatitis Other:_____________________________________________________

3. Family History- Circle ANY of the problems BLOOD relatives have had Diabetes Fibromyalgia Drug Addiction

Tuberculosis Chronic Pain Lupus

Heart Disease Psychiatric Problems Rheumatoid Arthritis

Vascular Disease Stroke Cancer

4. Social History: Marital Status:

Single

Do you SMOKE:

Yes

Do you drink:

Yes

Married No No

Widowed

Divorced

Separated

If yes, pack per day? _________ How often?

Daily

Weekly

Occasionally

Socially

Do you or have you use street drugs? Currently Past Circle any that apply: Marijuana Cocaine Amphetamine Heroin Have you ever participated in a rehabilitation program for alcohol or substance abuse? Yes

If so, for what substance? _______________________________________ Are you working? Yes No How many hours daily? 1 2 3 4 5 6 7 8 9 10+ Do you receive disability? Yes No Do you plan to return to work soon? Yes No Are you involved in a lawsuit related to your pain condition? Yes No Are your visits WORKMANS COMP claims? Yes No 5. Mental History: Do you currently take medications for mental health reasons? Yes Have you or do you currently see a psychiatrist or counselor? Yes Have you ever been counseled/treated for addiction? Yes No 6. Sexual History: Are you sexually active? Yes No Does your pain medication regimen affect your sexual relationship? Do you experience pain during intercourse? Yes No 7. Past Surgical History: Please List Surgeries, Dates, and Physicians 1. 2. 3. 4. 5. 6.

Date: Date: Date: Date: Date: Date:

Doctor: Doctor: Doctor: Doctor: Doctor: Doctor:

8. CURRENT MEDICATIONS: (use back of page if needed) Medication 1. 2. 3. 4. 5. 6. 7. 8.

Dose (mg)

How often a day?

No No

Yes

No

No

9. Onset: When did your pain/problem start? (Time frame/year) ____________________________________________________________________________ ____________________________________________________________________________ 10. Location/Duration: Describe where your pain is located and how long have you have had this pain? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ **Shade areas of Pain

Right

Left

Left

Right

11. Frequency of Pain: Circle ANY of the following that describe your pain Continuous

Brief

Sporadic

Rare

Constant with Flares

12. Pain Quality: Circle ANY symptoms that describe your pain Aching Hot-Burning

Throbbing Tingling

Shooting Numbness

Stabbing Dull

Sharp Cramping Pins & Needles Pressure

13. Circle any area that describes where the Pain Radiates Pain does not Radiate

Right Upper Extremity

Back Side of Both Thighs

Bilateral Lower Extremity

Bilateral Upper Extremities

Right Lower Extremity

Left Lower Extremity

Right Hand

Right Foot

Left Foot

Right Knee

Left Upper Extremity

Left Knee

Left Hand

Right Hip

Left Hip

14. Pain Level: (Scale of 0-10, No pain 0 - Worst pain 10) Worst Pain_________ Least Pain___________ Average Pain__________ Current Pain___________ 15. Worsening Factors: Circle ANY factor that worsens your pain Sitting

Standing

Walking

Lifting

Housework

Heat

Lying Flat

Bending

Twisting

Increased Activity

Cold Weather

Warm Weather

Coughing

Rainy Weather

Cold

Sexual Activity No Reason

16. Relieving Factors: Circle ALL that make your pain better Sitting

Standing

Walking

Cold Pack

Heating Pad

Medications

Exercise

Rest

Massage

17. Associated Symptoms: Circle ALL symptoms you have when you are in pain Nausea

Vomiting

Weakness

Falling

Frustration

Numbness

Tingling

Crying

Insomnia

Depression

Hostility

18. Does current medications help you pain? Yes No 19. Do you have side effects from current medications? Yes No If so, List:_______________ 20. Do you have medical history of fibromyalgia? Yes No 21. Do you use any assistive device? (please mark) Cane Crutches Walker Wheelchair None

22. Treatment History: Circle all Caregivers you have visited Pain Medicine Physician Physical Therapist General Surgeon

Family Physician Chiropractor Endocrinologist

Spine Surgeon Orthopedist Neurologist

Neurologist Psychiatrist Rheumatologist

23. Previous Tests Performed: Circle all that apply MRI CT Scan Bone Scan EEG Hepatitis Antibody

XRays EMG Test EKG Thyroid Panel No Testing

Discogram HIV/Aids Test

Myelogram Ultrasound

24. Please Circle ANY medications below that you have taken Ibuprofen

Aspirin

Robaxin

Flexeril

Lamictal

Topamax

Naproxen Motrin Advil Zanaflex Relpax

Doxepin Wellbutrin Zoloft Cymbalta Savella

Valium

Stadol

Tylenol

Baclofen

Remeron

Talwin Fioricet

Skelaxin, Norflex

Neurontin Gabapentin

Depakote Dilantin

Celexa

Celebrex

Elavil

Paxil

Pamelor

Prozac

Fiorinal

Lyrica

Pregabalin

Nortriptyline

Effexor

Amitriptyline

Risperdal

Ultram Ultracet Ketamine

Norco

Fentanyl Patch Duragesic Patch

Ms-Contin

Morphine Nucynta

Opana

Dilaudid

Hydromorphone

Zyprexa Lidocaine

Imitrex Guaifenesin Dextromethorphan Medrol DosePak Hydrocodone Oxycodone Percocet

Soma

Vicodin Oxycontin

Methadone

25. Please Circle ALL treatment you have received Acupuncture

Chemical Denervation

Epidural Steroid Injection Occipital Nerve Block Stimulation

Discography

Facet Injection RadioFrequency Ablation

TENS Unit

Heat

Epidural Blood Patch Nerve Block

Home Exercises

Sacroiliac Joint Injection Ice

Trigger Point

Massage

Spinal Cord Surgery

]26.

Please answer the following questions as honestly as possible, there are no wrong answers. SOAAP-R

How often do you have mood swings?

Never Often

Seldom

*

Sometimes

Often

Very

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

How often have you felt a need for higher doses of medication to treat your pain?

* *

How often have you felt impatient with your doctors?

* *

How often have you felt that things are just too overwhelming that you can’t handle them?

*

How often is there tension at home?

*

*

*

How often have you been concerned that people will judge you for taking pain medication?

*

How often do you count pain pills to see how many are remaining?

*

*

*

How often do you feel bored?

* *

How often have you taken more pain medication that you were supposed to?

* *

How often have you worried about being left alone?

* *

How often have you felt a craving for medication?

* *

How often have others expressed concern over your use of medication?

* *

How often have any of your close friends had a problem with drugs/alcohol?

* *

How often have others told you that you had a bad temper?

* *

How often have you felt consumed by the need to get pain medication?

* *

How often do you run out of pain medication?

* *

How often have others kept you from getting what you deserve?

* *

How often, in your lifetime, have you had legal problems or been arrested?

* *

How often have you attended an AA or NA meeting

* *

How often have you been in an argument that was so out of control that someone got hurt?

*

How often have you been sexually abused?

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

How often have others suggested that you have a drug or alcohol problem?

* *

How often have you had to borrow pain medications from family or friends?

* *

STOP BANG Questionnaire Do you snore loudly?

Yes

No

Do you often feel tired, fatigued, or sleepy during the daytime?

Yes

No

Has anyone observed you stop breathing during sleep?

Yes

No

Do you or are you being treated for High Blood Pressure?

Yes

No

Is your BMI more than 35?

Yes

No

Are you over 50 years old?

Yes

No

Is your neck circumference greater than 40cm?

Yes

No Not Sure

Are you Male?

Yes

No

Have you ever had a sleep study or wear Cpap or use Oxygen? If so when?______________________

Yes

No

Not Sure

High Risk of OSA: Answering yes to 3 or more questions Low Risk of OSA: answering yes to less than 3 questions

28. Review of Symptoms: Circle ANY of the symptoms you have had RECENTLY Cardiovascular:

Chest Pain Feet Swelling

Irregular Heartbeat

Constitutional Symptoms:

Fever

Endocrine:

Excessive Thirst

Eyes:

Blurred Vision

Gastrointestinal:

Abdominal Pain

Genitourinary:

Urinary Incontinence

HEENT:

Dizziness

Hematologic:

Abnormal Bleeding

Musculoskeletal:

Muscle Cramp

Weight Gain

Shortness of Breath

Weight Loss

Palpitations

Poor Appetite Sleep Difficulty Tiredness

Heat or Cold Intolerance Erectile Dysfunction Double Vision Nausea

Vomiting

Loss of Sexual Desire

Diarrhea

Constipation

Kidney Stones

Difficulty

Ear Pain

Bleeding Disorder

Neck Pain

Thyroid Trouble

Eye Pain

Pain during Urination

Hoarseness

Limb pain

Easy Bruising

Loss of Bulk Muscle

Back Pain

Joint Pain

Joint Stiffness

Joint Swelling

Arthritis

Limitation of Joint Movement

Muscle Tenderness

Neurological:

Headache Numbness Arm Numbness Leg Numbness Tremors Trouble with Memory Unsteady Walk Stroke Epilepsy/Seizures Sedation Spasticity

Psychological:

Depression

Respiratory:

Trouble Breathing

Skin

Rashes

Anxiety

Ulcers

Panic Attack Snoring

Infection

Trouble Concentration

Suicidal Ideation

Trouble Breathing during sleep Color Changes

Hypersensitivity

Cough

Wheezing

Congestion