Microsoft word - medical history form-spine

1499 BOARDMAN-CANFIELD RD BOARDMAN, OH 44512 WEBSITE: WWW.YOUNGSTOWNORTH.COM IMPORTANT INFORMATION: PLEASE BRING TO YOUR SCHEDULED APPOINTMENT ANY AND ALL FILMS (XRAYS, MRI, BONE SCAN, ETC) THAT YOU MAY HAVE HAD DONE. FAILURE TO DO THIS MAY CAUSE YOUR APPOINTMENT TO BE RESCHEDULED. CANCELLATIONS MUST BE MADE 24 HOURS IN ADVANCE OF THE SCHEDULED APPOINTMENT OR YOA RESERVES THE RIGHT TO ASSESS A FEE OF $25.00. COPAYS ARE DUE AT THE TIME OF VISIT. PLEASE PRINT AND FILL OUT PAPERWORK IN IT’S ENTIRETY AND RETURN TO YOA 5 DAYS PRIOR TO SCHEDULED VISIT. FAMILY PHYSICIAN:________________________REFERRING PHYSICIAN:_______________________
PATIENTS LEGAL NAME:__________________________________________DATE: ______/______/_____
STREET,CITY,STATE,ZIP:___________________________________________________________________

SS#:________/________/________ DATE OF BIRTH:_______/______/______ AGE:________

PHONE NUMBER: _________________________________ HEIGHT:_______ WEIGHT:________

LEFT HANDED
RIGHT HANDED

IS YOUR PROBLEM RELATED TO (CHECK ONE):

ACCIDENT
DATE PROBLEM OCCURRED: _________/________/________
PLEASE BRIEFLY DESCRIBE YOUR MAIN PROBLEM/COMPLAINT
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________


HOW LONG HAVE YOU HAD THIS PROBLEM? ________________________________

WHAT POSITION(S)/ACTIVITIES MAKE THE PAIN WORSE OR BETTER?
ACTIVITY
WORSE BETTER
BOWEL MOVEMENT
COUGHING
GENERAL ACTIVITY
HOME REMEDY
LYING DOWN
STANDING
HOW LONG CAN YOU STAND WITH MINIMAL OR NO PAIN (IN MINUTES)?_________________

WALKING DISTANCE WITH MINIMAL OR NO PAIN (CHECK BOX)
50-200 FT.
200-500 FT.

DO YOU NEED ASSISTANCE TO HELP YOU WALK?

IF YES, WHAT TYPE OF SUPPORT?_____________________________________________________________
DO YOU WEAR A BACK OR NECK BRACE?
IF YES, HOW LONG?__________________________________________________________________________
PHYSICIAN SIGNATURE:______________________________________________DATE:____________________________

PATIENTS LEGAL NAME:__________________________________________

LIST ALL THE PREVIOUS DOCTORS (MD, DO, CHIROPRACTOR)
YOU HAVE SEEN FOR YOUR MAIN COMPLAINT
PHYSICIAN
SPECIALTY
TREATMENT
INDICATE WHICH DIAGNOSTIC TESTS YOU HAVE HAD TO
EVALUATE YOUR MAIN COMPLAINT
PLAIN X-RAY
EMG/NCV/SSEP
BONE SCAN
ARTHROGRAM
MYELOGRAM
DEXA SCAN
DISKOGRAM
LIST ALL TREATMENTS YOU HAVE HAD PRIOR TO TODAY THAT ARE
RELATIVE TO YOUR CONDITION
TREATMENT
HELPFUL?
ELECTRICAL STIMULATION
TENS UNIT
ULTRASOUND
HOT PACKS
COLD PACKS
WHIRLPOOL
POOL EXERCISES
HOME EXERCISES
MANIPULATION
ACUPUNCTURE
INJECTIONS

PHYSICIAN SIGNATURE:______________________________________________DATE:____________________________

1499 BOARDMAN-CANFIELD RD BOARDMAN, OH 44512 WEBSITE: WWW.YOUNGSTOWNORTH.COM IMPORTANT INFORMATION: PLEASE BRING TO YOUR SCHEDULED APPOINTMENT ANY AND ALL FILMS (XRAYS, MRI, BONE SCAN, ETC) THAT YOU MAY HAVE HAD DONE. FAILURE TO DO THIS MAY CAUSE YOUR APPOINTMENT TO BE RESCHEDULED. CANCELLATIONS MUST BE MADE 24 HOURS IN ADVANCE OF THE SCHEDULED APPOINTMENT OR YOA RESERVES THE RIGHT TO ASSESS A FEE OF $25.00. COPAYS ARE DUE AT THE TIME OF VISIT. PLEASE PRINT AND FILL OUT PAPERWORK IN IT’S ENTIRETY AND RETURN TO YOA 5 DAYS PRIOR TO SCHEDULED VISIT. PATIENTS LEGAL NAME:__________________________________________
PAST MEDICAL HISTORY
HAVE YOU HAD ANY OF THE FOLLOWING? –CHECK ALL THAT APPLY
COMMENTS
COMMENTS
BOWEL DISORDERS
CANCER (WHERE)
PSORIASIS
DEPRESSION
RHEUMATISM
DIABETES
SEIZURES
HEART DISEASE
SERIOUS INFECTION
HIGH BLOOD PRESSURE
KIDNEY DISEASE
LUNG DISEASE
MULTIPLE MYELOMA
PACEMAKER
SURGICAL HISTORY
PLEASE LIST ANY SURGERY (S) YOU HAVE HAD BY TYPE, DATE AND OUTCOME:
ARE YOU ALLERGIC TO ANY MEDICATION (S)?
NO IF YES, WHAT TYPE OF REACTION (S)?
MEDICATION:
REACTION:
MEDICATION:
REACTION:
MEDICATION:
REACTION:
LATEX ALLERGIES:

TOBACCO USE

NO IF YES, AGE/YEAR STARTED: _________ YEAR QUIT:____________
PLEASE INDICATE QUANTITY PER DAY OF THE FOLLOWING
CIGARETTES
CHEWING TOBACCO (SNUFF)
ALCOHOL USE
NO IF YES, AGE/YEAR STARTED: _________ YEAR QUIT:____________
PLEASE INDICATE QUANTITY PER DAY OF THE FOLLOWING:
DISTILLED SPIRITS
HAVE YOU EVER BEEN TREATED FOR DRUG OR ALCOHOL ADDICTION?
PHYSICIAN SIGNATURE:______________________________________________DATE:____________________________

PATIENTS LEGAL NAME:__________________________________________
USING THE SYMBOLS BELOW, PLEASE DRAW IN THE LOCATION OF YOUR SYMPTOMS ON
THE DIAGRAMS.
FRONT BACK

XXXX PAIN 0000 NUMBNESS
____________________________________________________
PAIN SCALE: 0 1 2 3 4 5 6 7 8 9 10
MARK AN (X) ON THE LINE INDICATING THE USUAL DEGREE OF THE PAIN
(0 = NO PAIN, 10 = THE WORST PAIN IN YOUR LIFE, i.e. toothache, labor pain, kidney stone(s),etc.
IF YOU HAVE NECK PAIN, WHAT PERCENTAGE OF YOUR PAIN IS_______% NECK ________% ARM=100%
IF YOU HAVE BACK PAIN, WHAT PERCENTAGE OF YOUR PAIN IS_______% BACK ________% LEG=100%
PHYSICIAN SIGNATURE:______________________________________________DATE:____________________________

1499 BOARDMAN-CANFIELD RD BOARDMAN, OH 44512 WEBSITE: WWW.YOUNGSTOWNORTH.COM IMPORTANT INFORMATION: PLEASE BRING TO YOUR SCHEDULED APPOINTMENT ANY AND ALL FILMS (XRAYS, MRI, BONE SCAN, ETC) THAT YOU MAY HAVE HAD DONE. FAILURE TO DO THIS MAY CAUSE YOUR APPOINTMENT TO BE RESCHEDULED. CANCELLATIONS MUST BE MADE 24 HOURS IN ADVANCE OF THE SCHEDULED APPOINTMENT OR YOA RESERVES THE RIGHT TO ASSESS A FEE OF $25.00. COPAYS ARE DUE AT THE TIME OF VISIT. PLEASE PRINT AND FILL OUT PAPERWORK IN IT’S ENTIRETY AND RETURN TO YOA 5 DAYS PRIOR TO SCHEDULED VISIT. PATIENTS LEGAL NAME:__________________________________________
PLEASE LIST ALL MEDICATIONS YOU ARE TAKING
MEDICATION
DOSE: (MG.MCG)
TIMES PER DAY
HOW LONG?
HAVE YOU PREVIOUSLY TAKEN ANY OF THESE DRUGS?
SKELAXIN
CLINORIL
MECLOMEN
DARVOCET
NAPROSYN
TOLECTIN
DILAUDID
DISALCID
PARAFON FORTE
TYLENOL #3
PERCODAN
PREDNISONE
FELEDENE
FLEXERIL
VOLTAREN
IBUPROFIN
WORKING STATUS
FULL DUTY
LIGHT DUTY
OFF DUTY PER DR.
EMPLOYED
UNEMPLOYED

IF NOT FULL DUTY: HOW LONG HAVE YOU BEEN OFF WORK?
HAVE YOU HAD A WORK CAPACITY ASSESSMENT?
ARE YOU DISABLED THROUGH SOCIAL SECURITY?

MENTAL HEALTH
HAVE YOU/OR ARE YOU SEEING A DOCTOR FOR MENTAL ILLNESS:
IF YES, WITH WHOM?
FOR WHAT REASON?
MEDICATION(S):

PHYSICIAN SIGNATURE:______________________________________________DATE:____________________________

PATIENTS LEGAL NAME:__________________________________________
PHYSIC
REVIEW OF SYSTEMS
PLEASE CHECK IF YOU HAVE EXPERIENCED ANY OF THE FOLLOWING
WEIGHT GAIN LAST 6 MONTHS
WEIGHT LOSS LAST 6 MONTHS
NIGHT SWEATS
BLEED EASILY
ANY RASHES
BRUISE EASILY
RECENT CHANGE IN VISION
RECENT CHANGE IN SMELL
DIZZINESS
RECENT CHANGE IN HEARING
RECENT CHANGE IN TASE
SHORTNESS OF BREATH
WHEEZING
HISTORY OF TUBERCULOSIS
CHEST PAIN
SHORTNESS OF BREATH
FEET EDEMA (SWELLING)
WITH EXERCISE
PALPITATIONS
HEART MURMUR
PACE MAKER
DIARRHEA
ABDOMINAL PAIN
VOMITING
INDIGESTION
BLOODY OR DARK STOOLS
BLOOD IN URINE
UNABLE TO CONTROL BLADDER
RUSHING TO GO
URINARY TRACT INFECTION
UNABLE TO CONTROL BOWEL
NEED TO GO FREQUENTLY
ATTACK OF WEAKNESS
JOINT PAIN/SWELLING
/MORNING STIFFNESS
POOR APPETITE
NUMBNESS/TINGLING FEET
CRYING SPELLS
PROBLEM SLEEPING
NUMBNESS/TINGLING HANDS
CONVULSIONS
FEMALE – PLEASE WRITE IN DATE IF APPROPRIATE
ABNORMAL VAGINAL BLEEDING
HISTORY OF BREAST BIOPSY
HISTORY OF NIPPLE DISCHARGE
HISTORY OF ENDOMETRIOSIS
LAST MENSTRUAL PERIOD
MALE – PLEASE WRITE IN DATE IF APPROPRIATE
HISTORY OF PROSTATITIS
DIFFCULTY URINATING
LAST PROSTATIC EXAM
RECTAL EXAM
RESULTS:
PSA (PROSTATE BLOOD TEST)

RESULTS:
DESCRIBE CURRENT HEALTH, AGE, CAUSE OF DEATH, ILLNESS, DIABETES, CANCER, HYPERTENSION, ETC.
DECEASED
MEDICAL HISTORY/CAUSE OF DEATH
SIBLING (1)
SIBLING (2)
SIBLING (3)

PATIENT SIGNATURE:______________________________________ DATE: ______/______/_____

1499 BOARDMAN-CANFIELD RD BOARDMAN, OH 44512 WEBSITE: WWW.YOUNGSTOWNORTH.COM IMPORTANT INFORMATION: PLEASE BRING TO YOUR SCHEDULED APPOINTMENT ANY AND ALL FILMS (XRAYS, MRI, BONE SCAN, ETC) THAT
YOU MAY HAVE HAD DONE. FAILURE TO DO THIS MAY CAUSE YOUR APPOINTMENT TO BE RESCHEDULED. CANCELLATIONS MUST BE MADE 24
HOURS IN ADVANCE OF THE SCHEDULED APPOINTMENT OR YOA RESERVES THE RIGHT TO ASSESS A FEE OF $25.00. COPAYS ARE DUE AT THE
TIME OF VISIT. PLEASE PRINT AND FILL OUT PAPERWORK IN IT’S ENTIRETY AND RETURN TO YOA 5 DAYS PRIOR TO SCHEDULED VISIT.
LEGAL FULL NAME:_________________________________________________________________DATE:_____/_____/_____

PHONE NUMBER WE CAN REACH YOU OTHER THAN YOUR HOME TELEPHONE NUMBER:

CELL PHONE #:___________________ WORK PHONE:___________________________
OCCUPATION:_________________________________ EMPLOYER:_________________________________ YEARS THERE:____
EMPLOYERS STREET/CITY/STATE/ZIP:________________________________________________________________
NAME OF SPOUSE (IF APPLICABLE:)______________________________________BIRTHDATE:__________AGE:________

OCCUPATION:______________________EMPLOYER:__________________________________________ YEARS THERE:_____

EMPLOYERS STREET/CITY/STATE/ZIP:_________________________________________________________________________
MAY WE CONTACT HIM/HER AT WORK? YES
IF YES, PHONE NUMBER/EXT. ___________________
IN CASE OF EMERGENCY, WHO CAN WE CONTACT OUTSIDE OF YOUR HOUSEHOLD ?
NAME:________________________________________ RELATIONSHIP:_____________________________________________
PHONE #:________________ CAN WE USE CELL #? YES
I F YES, CELL# __________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FOR MINOR OR POWER OF ATTORNEY

RESPONSIBLE PARTY:______________________________________RELATIONSHIP TO PATIENT:___________________________
SS#:____/____/____ BIRTHDATE:___/____/____ AGE: ___
STREET/PO BOX:_____________________________CITY:_________________________________ST:______ ZIP:__________
TELEPHONE NUMBER:______________________ CELL PHONE NO.:_________________________
OCCUPATION:_____________EMPLOYER:______________________________ YEARS THERE:______

EMPLOYERS STREET/CITY/STATE/ZIP:_________________________________________________________________________

MAY WE CONTACT HIM/HER AT WORK? YES
IF YES, PHONE NUMBER/EXT. ___________________
_______________________________________________________________________________________________________________________________________________________________________________________
DO YOU WISH YOUR PHONE CALLS TO BE CONFIDENTIAL?
IS THIS VISIT DUE TO A WORK RELATED INJURY OR PROBLEM? IF YES, ON WHAT DATE DID THE INJURY OR PROBLEM OCCUR
________CLAIM NO.__________________
DID YOU REPORT THE ACCIDENT TO YOUR EMPLOYER?
WAS THIS THE RESULT OF AN AUTO ACCIDENT? YES
IF YES, DATE OF THE ACCIDENT____________
IS SOMEONE ELSE FINANCIALLY LIABLE FOR YOUR INJURY?
PRIMARY INSURANCE – NAME OF INSURANCE COMPANY:
INSURANCE ADDRESS (STREET/CITY/STATE/ZIP):

INSURED’S NAME: INSURED’S DATE OF BIRTH: EMPLOYER
POLICY/ID #: GROUP. NO.:

SECONDARY INSURANCE – NAME OF INSURANCE COMPANY:

INSURANCE ADDRESS (STREET/CITY/STATE/ZIP):

INSURED’S NAME: INSURED’S DATE OF BIRTH: EMPLOYER:

POLICY/ID # : GROUP. NO.:

PHYSICIAN SIGNATURE:______________________________________________DATE:____________________________

Source: http://www.youngstownortho.com/assets/files/patientForms/Medical%20History%20Form-Spine.pdf

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