EFTA00307789.pdf

Bernard A. Rawlins, M.D. NEW PATIENT INFORMATION FORM Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. If you already completed this form in the last 2 months, please fill out just the first 2 pages and only items on other pages that have changed since your initial visit. Thank you for your cooperation. Date: Date of Birth: Patient Name: Address: Home Phone: ( ) Work: ( ) How were you referred to Dr. Rawlins: ❑ Physician ❑ Patient/ Friend ❑ Insurance 0 Other: Referring Physician or Referral Source: - Address: City, State: Phone: ( ) Fax:( ) Do you want your medical records sent to this physician/ referral source? ❑ Yes ❑ No Primary Doctor: Address: City: Phone: ( ) Fax: ( ) Do you want your medical records sent to this physician? ❑ Yes E No Are there any other physicians to whom you would like your medical records sent? (Please include name and address) EFTA00307789 FEB.03.2059 15:15 ALEXISJIESS.EDU Digital 5117 14823 P001 ORTHO PAIN CHART ns using the appropriate Mark the areas on your body where you feel the described sensatio symbol from the list below. Please include all affectedareas. ==. 000 Burning xxx 1/11 = == Pins & Needles 000 = Aching = sm Stabbing = IIII Numbness = NI = == op° xxx no pain and Please indicate your current pain level by placing a line below with "0"- "10" = worst pain imaginable. Example: Pain Lo_ I I0 Pain on Average 10 0 Pain at its Worst 10 0 Pain at its Best L 10 (lying dom.roil) 0 EFTA00307790  HISTORY OF PRESENT COMPLAINT 1. Age: ❑ Male ❑ Female 2. Where is your problem located? ❑Neck ❑ Lower Back ❑ Arm I Leg ❑ Right ❑ Left 3. How long have you had this problem? Since? month day year 4. Briefly, please give the details of how this problem originally started: 5. Was this from a work-related injury? ONo ❑ Yes Have you missed any work days because of this problem? ❑ No ❑ Yes, how much? 6. Please describe your present pain/problem now (what you feel, where, when, etc.): 7. List all other physicians with whom you have consulted in the past year for this problem. 8. Have you had spinal surgery in the past: (Check one) ❑ Yes ❑ No How many times? What type of surgery(s) wasAvere performed? Discectomy ❑ Laminectomy ❑ Fusion ❑ Unknown ❑ Other What spinal level? What was the date of your most recent spine surgery? Did you improve from your spine surgery procedure(s)? ❑Yes ❑ No 9. Which of the following best describes the percentage of neck & arm or back & leg discomfort (if appropriate) Back Neck A. 100% back pain and 0% leg pain A. 100% neck pain and 0% arm pain B. 90% back pain and 10% leg pain B. 90% neck pain and 10% arm pain C. 75% back pain and 25% leg pain C. 75% neck pain and 25% arm pain D. 50% back pain and 50% leg pain D. 50% neck pain and 50% arm pain E. 25% back pain and 90% leg pain E. 25% neck pain and 75% arm pain F. 10% back pain and 90% leg pain F. 10% neck pain and 90% arm pain G. 0% back pain and 100% leg pain G. 0% neck pain and 100% arm pain 3 EFTA00307791  CURRENT PAIN PROFILE 10. Please choose letters A- F (in first column) to answer the questions in column two. A. Unable to tolerate How long can you sit? B. About 15 minutes only C. About 30 minutes only How long can you stand? D. About 45 minutes E. About 1 how How long can you walk? F. Indefinitely 11. Which of the following activities change the nature of your pain? Aggravates Relieves Pain Pain Neither Sitting ❑ ❑ ❑ Standing ❑ ❑ ❑ Walking ❑ ❑ ❑ Leaning fonvard (brushing teeth) ❑ ❑ ❑ Bending forward ❑ ❑ ❑ Lying on your side ❑ ❑ ❑ Lying on your back ❑ ❑ ❑ Lying on your stomach ❑ ❑ ❑ Rising from sitting ❑ ❑ ❑ Changing positions ❑ ❑ ❑ Coughing/ Sneezing ❑ ❑ ❑ Driving ❑ c ❑ Now go back and CIRCLE the box to indicate the most wizravatinz activity and the most relievine activity. 12. Does your pain wake you up at night? ONo ❑Yes ❑ Daily less than 3days/week Omore than 3 days/week 13. If your pain has changed, please indicate the most appropriate statement: (Circle one) A. My symptoms are more severe since the time of onset. B. My symptoms have remained the same since the time of onset. C. My symptoms are less severe since the time of onset. 14. Please indicate whether you have had any of the following studies and write yearAvhere the most recent was: YES NO YEAR/WHERE Regular X-ray of spine ❑ ❑ CT scan of spine ❑ ❑ MRI ❑ ❑ Myelogram ❑ ❑ Bone Scan ❑ ❑ 4 EFTA00307792 15. Of the following list of treatments, please indicate the effect of those which have been used in an attempt to help your present injury: (Check one of each) Type/ Duration (weeks/ months) Helpful No Help Not Used Anti-inflammatory ❑ ❑ ❑ Muscle Relaxants ❑ ❑ ❑ Narcotic Pain Medications ❑ ❑ ❑ Hot Packs ❑ ❑ ❑ Ice ❑ ❑ ❑ Ultrasound ❑ ❑ ❑ TENS Unit/ Muscle Stim ❑ ❑ ❑ Physical Therapy (Duration) ❑ ❑ ❑ Back/ Neck Exercises ❑ ❑ ❑ Chiropractor ❑ ❑ ❑ Epidural Block/ Injection ❑ ❑ ❑ Facet Block/ Injection ❑ ❑ ❑ Trigger Point Injection ❑ ❑ ❑ Acupuncture ❑ ❑ ❑ Other: ❑ ❑ ❑ Allergies Current Medications Medication Reaction Name Dose 5 EFTA00307793  MEDICAL HISTORY ❑ No medical problems Diabetes ❑ Bleeding disorders ❑ High blood pressure 0 Thyroid disease 0 Anemia ❑ Heart attack 0 Stomach ulcers O Blood clots in legs/ lung ❑ Heart failure O Irritable bowel O Endometriosis ❑ Abnormal heart rhythm 0 Stroke 0 Ovarian cysts ❑ Lung disease 0 Seizures 0 Anxiety ❑ Tuberculosis 0 Cancer — where? O Depression ❑ Asthma O Kidney Failure O Schizophrenia ❑ Bronchitis O Kidney Stones 0 Anorexia / bulimia ❑ Emphysema 0 Osteoporosis 0 Alcoholism ❑ Liver disease 0 Osteoarthritis ❑ Seen a psychiatrist ❑ Hepatitis O Rheumatoid arthritis ❑ HIV Are you under a doctor's care for any mother medical condition? ❑ Yes ❑ No If yes, please explain SURGICAL HISTORY Please choose all surgeries you have had ❑ Spine- Neck _Appendix / Intestine Eyes • Spine- Lower back • Hernia / Colon/ 0 Rectum Ears Brain : Hysterectomy / 0 C-section / E Female Nose Ileart • Kidneys / 0 Bladder / 0 Urinary Throat/ :Tonsils Angioplasty / = Stent • Shoulders / 0 Arms / 0 Hands .1 Prostate Lung • Hips / 0 Knees / 0 Legs / 0 Feet ❑Gallbladder/ ❑Stomach Other: SOCIAL HISTORY 16. Martial Status: ❑ Single ❑ Married ❑ Divorced ❑ Widowed 17. Number of Children: 18. I live: 0 Alone ❑ With: 19. Are you a cigarette smoker? ❑ Yes ❑ 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 12/ pack ❑ I pack ❑ More (How many?) 20. Do you drink any alcoholic beverages? (Check one) 0 None ❑ 1 to 2 drinks per day ❑ Socially ❑ Occasionally 21. Current work status: 0 Working full duty ❑ Working restricted duty (Since ) ❑ Retired ❑ Disabled (Since ) ❑ Student ❑ Homemaker ❑ Unemployed Company: Occupation: Title: 6 EFTA00307794 22. Have you ever had a problem with drug dependence? El Yes ❑ No 23. Are there any law suits pending or contemplated related to your problem? ❑ Yes ONo 24. Please write any additional information that you feel is important for us to know. REVIEW OF SYSTEMS Please check off any current or recent problems you have GENERAL DIGESTIVE GENITOURINARY ❑ Unexplained weight loss O Nausea or vomiting O Burning on urination Appetite change O Stomach pain or ulcers O Difficulty starting Fevers or chills O Heartburn urination Night Sweats O Frequent diarrhea O Incontinence Marked fatigue O Frequent constipation O Pelvic pain Difficulty Sleeping O Uncontrolled loss of O Urinate at night stool more than once EAR, NOSE, THROAT O Blood in stool O Unable to completely ❑ Difficulty swallowing O Hemorrhoids empty bladder ❑ Hoarseness ❑ Loss of hearing SKIN PSYCHIATRIC ❑ Ear pain O Frequent rashes O Depression ❑ Nosebleeds O Frequent itchiness O Anxiety O Easy bruising O Paranoia EYES O Swollen ankles O Obsessive / compulsive O Glasses behavior ❑ Change of vision NEUROLOGICAL O Seizures CARDIOVASCULAR O Blackouts/ fainting ❑ Heart or chest pain Tremor ❑ Abnormal heartbeat I leadaches/ migraines O Poor heart function MUSCULOSKELETAL LUNG O Joint pains/ Swelling ❑ Cough O Muscle Aches ❑ Shortness of breath 7 EFTA00307795