EFTA00313689.pdf

mistmisitimmiMedicine Intake Form: New ••••••••ilt44444444lif• sante Mrs ••••••• Patient Name: JEFFge‘l e*PS‘Te/r4 Today's Datej5/ i t 1,40 Date of Birth: Age: (..,"t Primary MD: ble. sk-tosr-oL Phone: .2 1 a - Sp- 9 V9S- on-z- CC: What problem/issue brings you here today? Referred By: Da itiCsKADLOLTZ- How and when did it start? What makes it worse? walking sitting standing I lying down (exercise nothing }Other: What makes it better? walking sitting standing I lying down exercise nothing Other. What do you want to accomplish from today's visit? Diagnosis I Treatm ent Options X-ray MR1 i Meds Review Test Injection Is this a Worker's Compensation Claim or is there litigat ion pending? Yes No What diagnostic tests have you had for this problem? None X-ray MRI CT EMG ics consult I What treatments have you had? None i Mel I Physical therapy 1 Chiropractor Psychotherapy Injections Surgery Please make a mark on the line below to indicate the level of discomfort you have today. No Pain 0 I 2 3 a 5 Worst Pain Ever 6 7 8 9 la Please describe what the pain feels like: Achy, Burning, Cramp ing, Stabbing, Stiff, Tingling, Numbness, Dull, Tight, Pulling Please describe the time course of your pain: Constant, Comes and goes, Getting worse, Getting better, Staying about the same Medical History: Diabetes, Cancer, High Blood Pressure, Pacemaker, Please shade all locations you Arthritis, Osteoporosis, Other. have pain or discomfort Surgical History: NJAL. Medications: (Use rt page V needed) Allergies to medicines: Family Histmy: (please include only Family member: Condition: I° degree relatives (parents, siblings. children)) (ag. strie't rheumatoid cribs-hit) Social History: What do you do for exercise? Tobacco use (cigarette, cigar, pipe, chew): Current Quit Number of alcoholic beverages per week? OcettWon: Physical requirementsTN:goosed Sitting Prolonged Standing Lifting) Travel iDrivingCompu ter Phone Childcare Employment status: 1 Full-time Part-time I Light Duty Off Duty due to injury Full-time Parent , Not working Retired Fenn, unintentional weight change? Yes 0 Vision change, double vision? Yes 110 Difficulty swallowing, headaches? Yes No Chest pain, palpitations? Yes tl, Shortness of breath, wheezing, cough after exercise? Yes 'es. Nausea, vomiting, black stools, loss of control of stools Yes ? 1 Loss of control of urine, urinary frequency or urgen cy? Yes o t, New rashes or psoriasis or skin lesions? Yes No Dizziness, weakness, numbness, tingling? Depressed mood, sleep problems, anxiety? eYes No No Current low back pain, other joint swelling or muscle pain? Yes No 2 Are you pregnant, trying to get pregnant or breast Yes No feeding? Patient's Signature: Last menstrual period date: Periods regular? Yes No Physician Initials/Date: 2 / / EFTA00313689