fidelity health and wellness center, llc pain … · varicose veins peripheral vascular disease...
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Page � of �1 16
!FIDELITY HEALTH AND WELLNESS CENTER, LLC
PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________
!Date of Initial Visit: ______________________________ PATIENT MEDICAL RECORD ID: _____________ !!
PATIENT REGISTRATION FORM Please complete all forms with blue or black ink only. !
PATIENT INFORMATION: Name: (Last) ___________________________________(First) ________________________(MI) ________ Suffix: ___________ !Maiden Name/Alias(es) used:___________________________________________________________________ !DOB: ________ -_________-___________ Age: ___________ SS # _______________________________ !Gender: Female Male Marital Status: Single Married Divorced Separated Widowed Engaged !Address:____________________________________City: ______________________State: _________ Zip Code: _________ !Home phone # ______________________________________ Work phone # ___________________________________ !Cell phone # _______________________________________ E-mail address: ___________________________________ !Do you have access to a computer with Internet? YES NO Would you like you medical information accessible through the Internet? YES NO !Driver’s License#:________________________________ State issued:_________________________ (Please give all available forms of identification to staff to include in your medical chart.) !!EMERGENCY INFORMATION Full Name:__________________________________ Relationship to patient: _______________________________________ !Phone(s): __________________________________________ !Address: __________________________________________ City:___________________State:______ Zip Code:________ !!RESPONSIBLE PARTY INFORMATION Last Name: _____________________________________ First Name:_______________________________ MI: ________ !Address: __________________________________________ City:___________________State:______ Zip Code:________ !Home Phone #:_____________________________________ Work Phone #:______________________________________ !Relationship to patient: ________________________________ !!
!!FIDELITY HEALTH AND WELLNESS CENTER, LLC !
Patient Name _____________________________________________________ DOB _________________________________ !HEALTH INSURANCE
Any form of health insurance? (Including Medicare, Medicaid/
State insurance, prescription) YES NO
[Please give insurance card(s) to the staff for record keeping in chart] !Primary Insurance Name: __________________________
Insured Last Name:________________________________
Insured First Name: ____________________ MI:_________
Insured SS#: _________________________
Insured DOB:______________________ Sex: M F
Policy/RID #:_____________________________________
Group #:________________________________________
Effective Date:____________________________________
Member ID #____________________________________
Employer: _______________________________________ !
!!Secondary Insurance Name: ________________________
Insured Last Name:________________________________
Insured First Name: ____________________ MI:_________
Insured SS#: __________________________
Insured DOB:______________________ Sex: M F
Policy/RID #:_____________________________________
Group #:________________________________________
Effective Date:____________________________________
Member ID #____________________________________
Employer: _______________________________________ !!!!REFERRAL INFORMATION
How did you hear about Fidelity Health and Wellness, LLC?
____________________________________________ !Were you referred? YES or NO !Referred By: ___________________________________ !
Address: ______________________________________ !City_____________________ State_________ Zip______ !Phone Number:___________________________________ !Referral Brought with you today? (Select one) YES NO
(please give referral form or letter to staff)!!EDUCATION
Are you a student? Yes □ No □ !If yes, FULL TIME PART TIME (circle one) !School Name ___________________________________ !!
!City___________________________State____________ !Highest Level of Education Achieved : High School/ Technical
school/ Vocational Program/ Associates Degree/ Bachelors
degree/ Masters Degree/ Doctorate !Degree Attained: _________________________________ !!
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!FIDELITY HEALTH AND WELLNESS CENTER, LLC
PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________
!EMPLOYMENT HISTORY Retired? : YES NO Date of retirement: ___________________________ !Disabled? YES NO If yes, (select one) Temporary Permanent Case worker name________________________________ !State _______ Contact Phone number: ________________ !Date Disability started: _______________________ !Currently employed? YES NO If yes, (select one). FULL TIME PART TIME !Current Occupation: ______________________________ !# of hours worked per week: ______________hours/week !What does your work involve? ________________________ _______________________________________________ _______________________________________________ !
Current Employer:_________________________________ !Current Work Address: _____________________________ !City:__________________ State: ________ Zip: _________ !Phone #: ________________________________________ !If not working, time since last unemployed? ____(months/years) !Do you wish to return to work? (Select one) YES NO !Previous Employer:_________________________________ !Address: ________________________________________ !City: __________________ State: ________ Zip: ________ !Phone #_________________________________________ !Why did you leave?_________________________________ !
!LEGAL INFORMATION Presently involved in a lawsuit? Yes No !Please provide details: ______________________________ _________________________________________________ !Attorney Name/Office:______________________________ !
Address:________________________________________ !City ___________________ State:________ Zip:________ !Office Phone number:________-_________-________ !Fax #: _________-________-___________
!Workman’s Compensation?: (Please circle one) Yes No !Name of Company:_______________________________ !Contact Name: __________________________________ !Phone #________________________________________ !Date of Injury:___________________________________ !Employer at time of Injury: __________________________ !
Employer Phone #:________________________________ !Car accident or Personal Injury case: Yes No !If yes, explain_____________________________________ !Contact Information: _______________________________ !Felony/Misdemeanor Case: (Select one) Yes No !If yes, explain____________________________________ _______________________________________________ !!
!
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!!FIDELITY HEALTH AND WELLNESS CENTER, LLC !
Patient Name _____________________________________________________ DOB _________________________________ !!GENERAL HEALTH OVERVIEW
Primary Care Physician’s Name/ Group:____________________ Phone #_________________________________________ !Address: _____________________________________________ City: _____________________State: _______Zip:________ !If No PCP, when and where did you last receive medical care and for what reason?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________ !!Height: ___________________ Weight: _____________________
ALLERGIES
Are you hypersensitive, intolerant or allergic to: !Any drugs, medications, injections?
Please
indicate___________________________________________ !Penicillin or other antibiotics Yes No
Demerol or other narcotics Yes No
Aspirin or other pain relievers Yes No
Morphine Yes No
Novocain or other anesthetics Yes No Tetanus
antitoxin or other serums Yes No
Iodine, merthiolates or other antiseptics Yes No !Any foods? ______________________________________ !Any chemicals or environmental substances______________ !Any side effects experienced to medications taken in the past
such as gastritis, nausea, or vomiting_____________________ !Have you ever had an allergy test? If yes, indicate when and
explain: _________________________________________ !Have you ever had diffiuclties with spinal , epidural or
anesthetics? ______________________________________ !
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!FIDELITY HEALTH AND WELLNESS CENTER, LLC
PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________
!MEDICAL HISTORY (Please circle all that apply)
Head/Eyes/Ears/Nose/Throat None
Cataract Glaucoma
Sinus Infection
Neurological/Psychological None
Headache TIA (mini stroke) Multiple Sclerosis Stroke/Paralysis Seizure/Epilepsy
Depression Anxiety
Eating Disorder
Heart None
Rheumatic fever Heart Failure
Abnormal Heart Rhythm High Blood Pressure
Endocrine None
Thyroid Disease Diabetes Mellitus Juvenile Diabetes
Gestational Diabetes
Lung None
Asthma Sleep Apnea Tuberculosis
Emphysema/COPD Pneumonia
Hematological/Oncological None
Cancer (Type) _____________________________ Chemotherapy
Radiation Anemia
Blood Clot (Leg _______ Lung ______ Other ______) Bleeding Tendency
Gastrointestinal None
Stomach/Duodenal Ulcer Cirrhosis
Hepatits (Type) ___________ Gallstones
Pancreatic Disease Esophagus Disease
Crohn’s or Colitis Diverticulitis
Acid Refulx/GERD
Peripheral vascular Aneurysm
Varicose Veins Peripheral Vascular Disease (PVD)
Genitourinary None
Kidney Infection Kidney Stones Kidney Failure
Dialysis Prostate Problems
Skin Skin Ulcer Psoriasis
Rash
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!FIDELITY HEALTH AND WELLNESS CENTER, LLC
PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________
!MEDICAL HISTORY (Please circle all that apply)
Head/Eyes/Ears/Nose/Throat None
Cataract Glaucoma
Sinus Infection
Neurological/Psychological None
Headache TIA (mini stroke) Multiple Sclerosis Stroke/Paralysis Seizure/Epilepsy
Depression Anxiety
Eating Disorder
Heart None
Rheumatic fever Heart Failure
Abnormal Heart Rhythm High Blood Pressure
Endocrine None
Thyroid Disease Diabetes Mellitus Juvenile Diabetes
Gestational Diabetes
Lung None
Asthma Sleep Apnea Tuberculosis
Emphysema/COPD Pneumonia
Hematological/Oncological None
Cancer (Type) _____________________________ Chemotherapy
Radiation Anemia
Blood Clot (Leg _______ Lung ______ Other ______) Bleeding Tendency
Gastrointestinal None
Stomach/Duodenal Ulcer Cirrhosis
Hepatits (Type) ___________ Gallstones
Pancreatic Disease Esophagus Disease
Crohn’s or Colitis Diverticulitis
Acid Refulx/GERD
Peripheral vascular Aneurysm
Varicose Veins Peripheral Vascular Disease (PVD)
Genitourinary None
Kidney Infection Kidney Stones Kidney Failure
Dialysis Prostate Problems
Skin Skin Ulcer Psoriasis
Rash
!!FIDELITY HEALTH AND WELLNESS CENTER, LLC !
Patient Name _____________________________________________________ DOB _________________________________ !
Any other medical conditions:___________________________
___________________________________________________
___________________________________________________ !!
Do you have any known contagious diseases at this time?
(Please circle one) YES NO
If yes, please indicate condition and how long? ___________
__________________________________________________
!PSYCHIATRIC HISTORY (Place a check mark if applicable)
_____Depression ____Anxiety _____Anger ____Mood Swings
_____Tension ____Other:_______________________________________________ !Under psychiatric care with:________________________________________ Phone #____________________________________ !!PAST SURGICAL HISTORY RELATED TO PAIN
Previous Surgeries (as related to the pain such as a laminectomy): (please indicate hospital and doctor/surgeon name)
!PAST SURGICAL HISTORY NOT RELATED TO PAIN
Musculoskeletal None
Rheumatoid Arthritis Gout
Lupus Serious Joint Injury Broken bone injury
Degenerative Arthritis
Other Alcoholism
Drug Abuse Immune Deficiency
Chronic Fatigue Syndrome Other ________________________________________ Other ________________________________________
Surgery Date Surgery Date
Surgery Date Surgery Date
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!FIDELITY HEALTH AND WELLNESS CENTER, LLC
PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________
!OB/GYNE HISTORY (Females Only)
Still have periods? YES NO !Regular monthly menstrual periods? YES NO
If no, explain: IRREGULAR?___________________________ !Menopause? YES NO !Hysterectomy or tubal ligation?________________________ !Heavy cycles? YES NO
# of days that period lasts? ___________________________ !History of Miscarriages YES NO !Ectopic Pregnancies YES NO !!
!!Abortions YES NO !Birth Control/OCPs YES NO !Date of last Pap smear: _____________________________ !Date of last Gyne Check-up :_________________________ !# of Children: ___________________________________ !# of Cesarean Sections? ____________________________ !# of Normal deliveries? (NSD/vaginal?)__________________ !# of children or grandchildren residing with you? __________ !Ages of children:__________________________________ !
!PERSONAL/SOCIAL HISTORY
With whom do you live? _____________________________ !Supportive relationship? YES NO !History of physical or emotional abuse? YES NO
Please provide details: _______________________________ !Are there any substance abuse issues/concerns in the
household? If yes, please explain:_______________________
__________________________________________________ !Physical abuse concerns? Explain: ______________________
__________________________________________________
!Are you able to take care of yourself? YES NO
If NO, name of caregiver:____________________________ !Main interests and hobbies? __________________________ !Activity Level: (select one) sedentary active
Exercise? (Select one) YES NO
Type of exercise:_______________# times per week ______ !Do you wear your seat belt? (Select one) YES NO !Do you have a religious/spiritual practice? YES NO
If yes, PLEASE INDICATE? ___________________________ !!
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!!FIDELITY HEALTH AND WELLNESS CENTER, LLC !
Patient Name _____________________________________________________ DOB _________________________________ !!SUBSTANCE ABUSE
Tobacco Use? YES NO
Have you ever smoked cigarettes? (Select one) YES NO !Amount per day: ____________packs/day for ________ years !If you have quit smoking, when did you stop?______________ !Alcohol Use? YES NO
If yes, frequency? □ Daily □ Few per week □ Special Occasions
□ Rarely !Type of alcohol_________________________________ !History of alcohol abuse? (Select one) YES NO !History of Treatment of any kind? (Select one) YES NO !WHERE_____________________________________________
___________________________________________________ !History of drug or illicit substance abuse? (Select one)
YES NO
!ANY Treatment? (Select one) YES NO
WHERE?____________________________________________
___________________________________________________ !Which of the following drugs or substances, if any, have you
used in the PAST or PRESENTLY USING ? (Check all that apply)
Next to each drug/substance checked, please indicate if you
used it: Occasionally ("O"), Frequently ("F"), or Continuously
(“C”). Indicate Date of Last Use if applicable. !Alcohol ____ O F C Date: _________ !Barbiturates ____ O F C Date: _________ !Cocaine _____ O F C Date: _________ !Heroin _____ O F C Date: _________ !Other ______ O F C Date: _________ !Amphetamines ___O F C Date: _________ !Marijuana _____ O F C Date: _________ ! !
!
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!FIDELITY HEALTH AND WELLNESS CENTER, LLC
PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________
!PAIN HISTORY
Briefly list the main reason(s) for your visit today: ______________________________________________________________ !How did your pain problem first start (Describe)? ______________________________________________________________ !How long have you had this pain? __________________________________________________________________________ !Please describe what your pain is like: (Please circle all that apply) Sharp
Shooting
Burning
Pressure
Throbbing
Cramping
Achy
Constant
Stabbing
Gnawing
Tender
Comes and goes!When is your pain the worst? Morning Afternoon Evening Night Varies All of the time !Are you awakened at night by your pain? YES NO !What improves your pain? _______________________________________________________________________________ !What worsens your pain? _______________________________________________________________________________ !!At any given time, think of your pain intensity as falling somewhere on a scale of 0 to 10. Please rate your pain on the following
diagrams:
0= No pain 10=Very severe pain !
!!
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!FIDELITY HEALTH AND WELLNESS CENTER, LLC
PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________
!PAIN HISTORY
Briefly list the main reason(s) for your visit today: ______________________________________________________________ !How did your pain problem first start (Describe)? ______________________________________________________________ !How long have you had this pain? __________________________________________________________________________ !Please describe what your pain is like: (Please circle all that apply) Sharp
Shooting
Burning
Pressure
Throbbing
Cramping
Achy
Constant
Stabbing
Gnawing
Tender
Comes and goes!When is your pain the worst? Morning Afternoon Evening Night Varies All of the time !Are you awakened at night by your pain? YES NO !What improves your pain? _______________________________________________________________________________ !What worsens your pain? _______________________________________________________________________________ !!At any given time, think of your pain intensity as falling somewhere on a scale of 0 to 10. Please rate your pain on the following
diagrams:
0= No pain 10=Very severe pain !
!!
!!FIDELITY HEALTH AND WELLNESS CENTER, LLC !
Patient Name _____________________________________________________ DOB _________________________________ !!In each section, Check one item that best describes you pain. If the section has no description that applies to your pain, please skip
that section
!!
!
flickering
quivering
pulsing
throbbing
beating
pounding
pinching
pressing
gnawng
cramping
crushing
dull
sore
hurting
aching
heavy
fearful
frightful
terrifying
spreading
radiating
penetrating
piercing
lumping
flashing
shooting
lugging
pulling
wrenching
tender
taut
rasping
splitting
punishing
grueling
cruel
vicious
killing
light
numb
drawing
squeezing
tearing
pricking
boring
drilling
stabbing
lacinating
hot
burning
scalding
searing
tiring
exhausting
wretched
blinding
cold
cool
freezing
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!FIDELITY HEALTH AND WELLNESS CENTER, LLC
PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________
What were you doing when it first happened?____________ !When did it happen again?_____________________________ !Did you go to a doctor or hospital?_____________________
Where?____________________________________________
When?_____________________________________________ !Did you take anything?________________________________
Were you prescribed any medications or therapies? WHAT?
__________________________________________________ !Any diagnostics studies done?__________________________
WHERE? ___________________________________________
WHEN? ____________________________________________ !Did the doctor/hospital refer you to any doctors or for
follow-up ?__________________________________________
WHO? _____________________________________________
WHERE? ___________________________________________
!How bad does it get? _____________________/10
(0-10. 0= no pain, 10 = worst pain of your life) !Does it stay in one area or do you feel it in other places?
If yes, Where? ______________________________________ !Is it every day? YES NO !DId anyone tell you what was wrong? ___________________
Any other details? ___________________________________ !On a scale of 0-10, please indicate the PAIN LEVEL:
O= no pain, 10= worst pain of your life
Pain Level Today _____/10
Average level _____/10 without taking any medication
Average level _____/10 while taking any medication
Pain at Rest _____/10
Pain with Movement _____/10
!!!On the diagram, shade the areas where you feel the pain: !!!!!!!!!!!!!!!!
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!FIDELITY HEALTH AND WELLNESS CENTER, LLC
PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________
!Have you ever been referred or used any of the following alternative treatments? (Please complete the table below)
!CURRENT MEDICATIONS/ SUPPLEMENTS
Please list any prescription, over the counter (OTC) medications, or vitamins/ supplements you are currently taking including dosages: !PRESCRIPTION MEDICATIONS
!OTC MEDICATIONS (Ibuprofen, NSAIDS, Antacids, sleep aids, laxatives)
!VITAMINS/ SUPPLEMENTS
!
Adjunctive treatment
Referred by Done by Address City, State Phone # Dates
Occupational/Physical Therapy ChiropractorAcupunctureMassageHydrotherapyNerve BlocksTENS UNITBiofeedbackHypnosisCounseling
Prescription Medications (Name) Dose (mg) Frequency (How many times a day) Prescribed by:1.
2.
3.
4.
5.
Medications (Name) Dose (mg) Frequency (How many times a day) How long?1.
2.
3.
Medications (Name) Dose (mg) Frequency (How many times a day) How long?1.
2.
3.
!!FIDELITY HEALTH AND WELLNESS CENTER, LLC !
Patient Name _____________________________________________________ DOB _________________________________ !Previous Pain Clinic/Doctor: _____________________________________________________________________________ !Address:___________________________________________________City_____________________State_____________ !Phone # _______________________________________ Fax: ________________________________________________ !Other Pain Management Clinic or Doctor seen:_______________________________________________________________ !Address:___________________________________________________City______________________________State_____ !Phone # _______________________________________ Fax: ________________________________________________
!OPIATE HISTORY:
Have you taken any of the following medications now or in the past? (Please circle all that apply) OXYCODONE
PERCOCET
METHADONE
OXYCONTIN
OPANA
HYDROCODONE
TRAMADOL
FENTANYL
LYRICA
GABAPENTIN
SOMA
XANAX
VALIUM
ATIVAN
IBUPROFEN
FLORINAL
FLEXERIL
OTHER _____________ !
Please specify below information for those noted to be taken:
!Any adverse reactions or side effects to the medications noted above? (Select one) YES NO
If yes, please indicate details: ____________________________________________________________________________ !Have you ever taken SUBOXONE? YES NO If yes, please explain ______________________________ !Have you ever been to an In or Outpatient rehabilitation clinic, center, or program? (Please circle one) YES NO
If yes, please
explain_____________________________________________________________________________________________ !Any other medications taken for pain: ______________________________________________________________________ !
Medications taken (Name)
Dose (mg) Frequency (how many times per day)
Prescribed by (Dr?) When? (dates)
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!FIDELITY HEALTH AND WELLNESS CENTER, LLC
PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________
!Have you ever been referred or used any of the following alternative treatments? (Please complete the table below)
!CURRENT MEDICATIONS/ SUPPLEMENTS
Please list any prescription, over the counter (OTC) medications, or vitamins/ supplements you are currently taking including dosages: !PRESCRIPTION MEDICATIONS
!OTC MEDICATIONS (Ibuprofen, NSAIDS, Antacids, sleep aids, laxatives)
!VITAMINS/ SUPPLEMENTS
!
Adjunctive treatment
Referred by Done by Address City, State Phone # Dates
Occupational/Physical Therapy ChiropractorAcupunctureMassageHydrotherapyNerve BlocksTENS UNITBiofeedbackHypnosisCounseling
Prescription Medications (Name) Dose (mg) Frequency (How many times a day) Prescribed by:1.
2.
3.
4.
5.
Medications (Name) Dose (mg) Frequency (How many times a day) How long?1.
2.
3.
Medications (Name) Dose (mg) Frequency (How many times a day) How long?1.
2.
3.
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!!FIDELITY HEALTH AND WELLNESS CENTER, LLC !
Patient Name _____________________________________________________ DOB _________________________________ !!
FAMILY HISTORY (Please indicate which are medical conditions prevalent and to whom in your family?) □ OBESITY __________________________
□ HIGH CHOLESTEROL ___________________
□ DIABETES__________________________
□ LUNG DISEASE/ASTHMA/EMPHYSEMA
__________________________________
□ ALLERGIES__________________________
□ HIGH BLOOD PRESSURE _________________
□ KIDNEY DISEASE _____________________
□ HEART DISEASE/STROKE _______________
□ BLEEDING DISORDER __________________
□ CANCER__________________________
□ AUTOIMMUNE DISORDERS______________
□ OSTEOPOROSIS_____________________
□ PSYCHIATRIC (DEPRESSION, EATING DISORDER,
ALCOHOLISM) _______________________________
□ OTHER_______________________________________
□ OTHER ______________________________________!REVIEW OF SYSTEMS: Check all that apply. . Have you experienced any of the following symptoms in the past 4 weeksGeneral
None
weight change
appetite change
fever, chills, sweats
dizziness, fainitng
Head/Eyes/Ears/Nose/Throat
None
vision change
hearing change
dry mouth
difficulty swallowing
mouth sores
Cardiopulmonary
none
shortness of breath
chest pain
swollen ankles
coughing up blood
rapid heart rate
Gastrointestinal
None
heartburn
nausea
abdominal pain
constipation
diarrhea
bleeding from the rectum/black colored bowel movements
Genitourinary
None
problems with passing urine
urine leakage
menstrual problems
I may be pregnant
pain with passing of urine
Musculoskeletal/Neurological
None
Headache
Joint pain
joint swelling
stiff muscles
painful muscles
weakness
numbness/tingling sensation Where? __________________________
back pain
neck pain
Skin
None
rashes
skin ulcers
Peripheral Vascular
None
Cool hands/feet
Color change
Leg pain when walking
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!FIDELITY HEALTH AND WELLNESS CENTER, LLC
PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________
!PHYSICIANS SEEN IN THE PAST
!!
HOSPITALS
Have you been to any of the following hospitals? (Please circle all that apply) SOUTHERN MD
CALVERT MEMORIAL
NOVA
CIVISTA MEDICAL CENTER
ST, MARY’S COUNTY
PRINCE GEORGES COUNTY
HOSPITAL
ANNE ARUNDEL MEDICAL CENTER
PG SHOCK TRAUMA
JOHNS HOPKIN’S MEDICAL CENTER
WASHINGTON HOSPITAL CENTER
HOWARD
GEORGE WASHINGTON UNIV MC
GEORGETOWN UNIVERSITY
HOSPITAL
OTHER:_______________________
OTHER:_______________________!
!
Doctor/Group Name
Type Phone # Fax # Address, City, State Date last seen
PCPPain managementOrthopedicNeurologist Dentist
Hospital Name City, State
Phone# Fax # Reason for last visit
Date of last visit
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!!FIDELITY HEALTH AND WELLNESS CENTER, LLC !
Patient Name _____________________________________________________ DOB _________________________________ !!
PREVIOUS LABORATORY WORKUP (Please include all laboratory workup done including hospitals)
!!
PREVIOUS DIAGNOSTICS: MRIS, XRAYS, CT-SCANS, EMG-NCV, Myelogram
(Please include all diagnostic workup done in the table below.)
!!
PHARMACIES USED
(Please circle all that apply and give specific details below) CVS
RITE AID
WALGREENS
ACCOKEEK
FRIENDLY
FAMILY CARE 1,2, 3
TIDEWATER
TARGET
WAL-MART
SAM’S CLUB
NORTH GATE CARE
REYNOLD’S
PROSPERITY
OTHER________________________
OTHER________________________!
Location Name
Phone# Address, City, State
Diagnostic done Date of last workup done
LabCorp
Quest
Kaiser
Diagnostic done Location Name Phone# ADDRESS Date done
Pharmacy Name Phone# Location Date of last visit
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