|
Which of the following of our marketing have you seen?
|
|
|
Direct Mail
|
Friend (Who?)
|
|
Sign
|
Magazine (Which one?)
|
|
Internet
|
Health Talk
|
|
Other
|
|
|
What specifically prompted you to choose us for your healthcare needs?
|
|
|
Name of Primary Care Provider:
|
City, State
|
|
Last Check-Up
|
|
|
Are you under a doctor's care at the present time?
|
If yes, for what?
|
|
Name of Doctor:
|
City, State:
|
|
Who may we thank for referring you?
|
|
|
Medical History
|
|
|
|
|
|
Gynecologic History
|
|
|
Are you currently pregnant?
|
Pregnancies #
|
|
Dates:
|
|
|
Deliveries #:
|
Natural Delivery or C-section?
|
|
Menstrual - Onset:
|
Menstrual - Duration:
|
|
Are they regular?
|
Pain Associated?
|
|
Last Menstrual Period:
|
|
|
General History
|
|
|
(Check all that apply to you)
• • •
|
Other:
|
|
Family History
|
|
|
Possible Hereditary Diseases
|
|
|
Social Habits
|
|
|
Smoking
|
Packs Per Day
|
|
Alcohol
|
Drinks/week
|
|
Coffee/Caffeine
|
Drinks/Cups Per day
|
|
High Stress Level
|
Reason
|
|
Medications
|
|
|
Medication
|
Dosage:
|
|
Medication
|
Dosage:
|
|
Medication
|
Dosage:
|
|
Medication
|
Dosage:
|
|
Medication
|
Dosage:
|
|
Medication
|
Dosage:
|
|
Medication
|
Dosage:
|
|
Medication
|
Dosage:
|
|
|
|
|
Birth Control:
|
|
|
Medication Allergies
|
General Allergies
|
|
Do you have any surgical devices in your body (i.e. screws, pins, plates, etc)?
|
If yes, where are they located?
|
|
Activity Level
|
|
|
Select one of the following:
|
|
|
Surgical History
|
|
|
Past Surgical History (list all)
|
|
|
Nutrition
|
|
|
Present Height - Feet
|
Present Height - Inches
|
|
Present Weight (lbs)
|
Ideal Weight (lbs)
|
|
Physical Medicine Current Conditions
|
|
|
Reason For Visit?
|
When did your symptoms appear?
|
|
is this condition getting progressively worse?
|
Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)
|
|
Type of pain
• • •
|
How often do you have this pain?
|
|
Is it constant or does it come and go?
|
Does it interfere with your
• • •
|
|
What treatment have you received for your condition?
• • •
|
Other:
|
|
Name & Address of other doctor(s) who have treated you for your condition:
|
|
|
|
|
|
Date of Last physical exam?
|
Date of last Spinal Exam/X-Ray
|
|
Date of last Lab work
|
Date of last Chest X-Ray
|
|
Date of last MRI, CT-Scan, Bone Scan
|
|
|
|
|
|
Is your condition due to an accident?
|
Date of Accident:
|
|
Type of accident
|
Other
|
|
To whom have you made report of your accident?
|
|
