Microsoft word - registration form.docx

PATIENT’S NAME_________________________ AGE_______ DATE OF BIRTH___________ EXPLAIN BRIEFLY WHAT SYMPTOMS BRING YOU TO THIS OFFICE: ARE ANY OF YOUR PRESENT PROBLEMS DUE TO INJURY? Yes____, No___ ARE YOU RIGHT-HANDED [ ] OR LEFT-HANDED [ ]? PAST MEDICAL HISTORY:
1. HAVE YOU EVER HAD: (Check the appropriate boxes and list year to the right) 2. PLEASE LIST IN CHRONOLOGICAL ORDER ALL HOSPITALIZATIONS, SERIOU, ILLNESSES, OPERATIONS, SEVERE INJURIES, AND BROKEN BONES. Attach a separate page for this if needed. 1835 Park Avenue San Jose, CA 95126-1650 phone:(408)279-3330 email: [email protected] 3. PLEASE LIST MEDICATIONS THAT YOU ARE CURRENTLY TAKING: (Please bring your medications with you to your office visit.) Attach a separate page for this if needed 4. HAVE YOU EVER TAKEN?: (Please check the appropriate boxes) [ ] Injected Biological Drugs for Arthritis or Myochrysine or Solganol, By Injection,___ [ ] Cortisone - By Mouth___, By Injection___ [ ] Tolectin (tolmetin). [ ] Other Arthritis Medications? 5. PLEASE LIST ALL MEDICATIONS THAT YOU do not tolerate or are allergic to: 6. PLEASE LIST ALLERGIES OTHER THAN DRUG RELATED:_________________________ ____________________________________________________________________________ ____________________________________________________________________________ 7. HAVE YOU RECENTLY RECEIVED PHYSICAL THERAPY? 8. WHEN WERE YOU LAST IMMUNIZED AGAINST: [ ] German Measles [ ] Tetanus [ ] Influenza [ ] Pneumococcus [ ] Hepatitis B Your present status:______________________________________How Long?_____________ Spouse: Occupation__________________________ Health_________________Age________ Are you satisfied with your present marital status? ____________________________________ 1835 Park Avenue San Jose, CA 95126-1650 phone:(408)279-3330 email: [email protected] Work: Hours per week ______________________Occupation___________________________ Have you missed work due to this illness or injury? Yes_ No __. If Yes, please explain________ ____________________________________________________________________________ Date last worked: ______________________________________________________________ Date returned to part-time work:___________________________________________________ Date returned to full-time work: ___________________________________________________ Birthplace: _______________________Your Ethnic Origin _____________________________ How long have you been in Santa Clara County? _____________________________________ With whom do you live? _________________________________________________________ Do you exercise regularly?_______________________________________________________ Do you follow a special diet? _____________________________________________________ How much tobacco per day? _____________________________________________________ Alcohol: Daily__, Occasionally__, Rarely___ Never___. 11. FAMILY HISTORY: (Please list each member separately) HAS ANY BLOOD RELATIVE HAD: (Please list who) [ ] Osteoarthritis (degenerative arthritis) 1835 Park Avenue San Jose, CA 95126-1650 phone:(408)279-3330 email: [email protected] [ ] Swollen Joints - where?_ [ ] Painful Joints - where?_ [ ] Morning Stiffness - where?. How Long (Hours before improvement)? [ ] Neck Pain [ ] Upper Back Pain [ ] Lower Back Pain [ ] Heel Pain [ ] Muscle Pain [ ] Muscle Weakness [ ] Psoriasis [ ] Lumps or Nodules [ ] Skin Sensitivity to Sunlight [ ] Change in Skin Texture, Color, or Moisture [ ] Easy Bruising or Bleeding [ ] Skin Ulcers [ ] Abnormal Hair Loss [ ] Fingers Turning While on Exposure to Cold [ ] Heartburn [ ] Nausea [ ] Vomiting [ ] Vomiting Blood [ ] Abdominal Pain [ ] Constipation [ ] Diarrhea [ ] Yellow Jaundice [ ] Recent Change in Bowel Habits [ ] Stools Which Are ( )Black; ( )Bloody [ ] Fever [ ] Shaking Chills [ ] Excessive or Unusual Fatigue [ ] Recurrent Infections [ ] Swollen Glands [ ] Glaucoma (increased eye pressure) [ ] Kidney Stones [ ] Diabetes [ ] TB [ ] Cancer [ ] Birth Defects [ ] Stroke [ ] Blood Disorders [ ] Alcoholism, [ ] Drug Addiction [ ] Double Vision [ ] Persistent Dry Eyes [ ] Eye Inflammation [ ] Glaucoma [ ] Cataracts [ ] Glasses [ ] Do you use artificial tears? 1835 Park Avenue San Jose, CA 95126-1650 phone:(408)279-3330 email: [email protected] [ ] Mouth Ulcers [ ] Persistent Dry Mouth [ ] Hoarseness [ ] Sore Throats [ ] Jaw Pain With Chewing [ ] Difficulty Swallowing [ ] Cough [ ] Coughing Up Blood [ ] Leg Swelling [ ] Palpitations [ ] Frequency of Urination ( )Times per day, ( )Times per night [ ] Burning with Urination [ ] Blood in Urine [ ] Urgency of Urination [ ] Discharge From the Penis [ ] Excessive Vaginal Discharge [ ] Difficulty Starting ___ or Stopping___ Flow of Urine [ ] Rash or Sores on Genitals [ ] Unusual Cold Intolerance [ ] Excessive Thirst [ ] Excessive Urination [ ] Excessive Appetite [ ] Loss of Appetite [ ] Weight Loss Gain Since When?_ [ ]Hot Flashes [ ] Headaches: ( )Migraine, ( )Sinus, ( )Tension [ ] Numbness, Burning, or Tingling - Where? [ ] Loss of Memory [ ] Loss of Consciousness [ ] Nervousness [ ] Depression [ ] Suicidal Ideas [ ] Difficulty Sleeping [ ] Any Other Medical Problems or Symptoms? Age at Onset __________________________ Duration of Flow________________________ Days Between Periods___________________ Symptoms with Periods __________________ First Day of Last Period __________________ Number of Pregnancies__________________ Please bring with you the names and addresses where pertinent medical records, laboratory tests, and x-rays might be obtained. We can then request what records we need. Thank You. 1835 Park Avenue San Jose, CA 95126-1650 phone:(408)279-3330 email: [email protected]

Source: http://baacare.com/pdfiles/medicalhistoryform.pdf