rejuv medical sw - new patient health analysis€¦ · review of systems mark any events that have...
TRANSCRIPT
Name: Date of Birth:
Primary Care Physician:
Who referred you?
NEW PATIENT HEALTH ANALYSIS
The following pages are used by our team to help assemble a complete assessment of your health. Be as accurate and
complete as possible. If you have any questions contact us at [email protected] or by phone at 520-777-
9385. If you prefer to fax the form back our fax number is 520-306-4843.
GOALS FOR TREATMENT
In the space provided below outline the end result you would like to achieve with our assistance. Explain your goals for
your health.
Do you perceive any barriers to achieving your goals?
What one improvement in your health would have the greatest impact on your life?
HOW CAN WE HELP YOU?
Recover from injury Functional Medicine/health optimization
Eliminate pain Weight loss
Boost energy level Functional movement restoration
Improve sleep Build strength/endurance
Reduce/manage stress Improve/optimize nutrition
Investigate food/environmental allergens Sport/recreation specific fitness and training
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Name: Date of Birth:
Primary Care Physician:
Who referred you?
TIMELINE AND DESCRIPTION
In the space provided below describe the issue(s) you would like to address. Provide a timeline of the issue and what has
been done to help you so far.
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Name: Date of Birth:
Primary Care Physician:
Who referred you?
PAIN AND DESCRIPTION
*If you are not seeking help for pain, skip this page.
How much do you hurt right now? 1 2 3 4 5 6 7 8 9 10
On average what is your daily pain score? 1 2 3 4 5 6 7 8 9 10
Indicate the location of your pain by marking the diagram with an x.
Check all of the following that describe of your pain:
Aching Sharp Exhausting
Throbbing Tender Tiring
Shooting Hot/Burning Sickening
Stabbing Cramping Fearful
Gnawing Heavy Punishing-Cruel
The Pain Started: Gradually Suddenly Onset Rate
The Pain Is: Constant Intermittent
The Pain Is Worst: Morning During The Day Evenings During Sleep
Does The Pain Radiate? Yes No Where?
The Pain Is Made Better By:
The Pain Is Made Worse By:
Are There Any Other Symptoms Associated With The Pain? Yes No
If yes, explain:
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Name: Date of Birth:
Primary Care Physician:
Who referred you?
DIAGNOSTIC TESTS AND IMAGING What diagnostic workup have you had for the issue?
Mark all of the following tests you have had that are related to your current pain complaints:
I HAVE NOT HAD ANY DIAGNOSTIC TESTS PERFORMED FOR MY CURRENT PAIN COMPLAINTS.
MRI of the Date: Facility:
X-rays of the Date: Facility:
CT scan of the Date: Facility:
EMG/Nerve conduction study of the Date: Facility:
Other diagnostic testing Have you seen any other specialists for this problem? Yes No If yes, who, what specialty, and what treatment was offered?
TREATMENT AND HISTORY
What treatment have you has for the issue?
Mark all of the following pain treatments you have undergone prior to today’s visit:
I HAVE NOT HAD ANY PRIOR TREATMENTS FOR MY CURRENT COMPLAINTS. Chiropractic Physical Therapy Psychological Therapy/Counselling Spine Surgery Podiatrist Treatment Discogram (check all that apply) Cervical Thoracic Lumbar Epidural Steroid Injection (check all that apply) Cervical Thoracic Lumbar Joint Injection – What joint: Medial Branch Blocks or Facet Injections (check all that apply) Cervical Thoracic Lumbar Nerve Blocks – Area/Nerve(s) Radiofrequency Ablation – (check all that apply) Cervical Thoracic Lumbar Spinal Column Stimulator – Trial only Permanent Implant Trigger Point Injection – Where? Vertebroplasty / Kyphoplasty – Level(s) Medications (Past)
Name of Medication Strength How did you take it? Why was it stopped?
Other treatments______________________________________________________________
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Name: Date of Birth:
Primary Care Physician:
Who referred you?
REVIEW OF SYSTEMS
Mark any events that have occurred in the LAST MONTH:
General:
Weight Loss Weight Gain Belts fit differently Excessive thirst
Loss of appetite Always tired Increased appetite Night sweats
Chills Puffiness Lack of sex drive Hot flashes Intolerant of cold Frequent infections Unable to orgasm Fever Swelling Changes in Hair Changes in nails
Head/Eyes/Ears/Nose/Throat:
Allergies (seasonal) Nasal discharge Nasal congestion Hearing loss Sinus pain Ear pain Ear discharge Tooth pain
Change in vision Sore mouth Trouble swallowing
Bleeding gums Hoarseness Sore throat
Respiratory:
Shortness of Breath Wheezing Breathing discomfort Sleep apnea
Cough Blood sputum Snoring
Cardiovascular:
Chest pain Fainting Irregular heartbeat Bleeding disorder
Swelling in the Feet High blood pressure Deep vein thrombosis Lightheadedness
Ankle swelling Calf or leg pain Shortness of breath during sleep
Gastrointestinal:
Nausea Vomiting/dry heaves Bloating Bloody stools
Excess gas Heartburn Dark and tarry stools
Diarrhea Constipation Abdominal pain
Rectal pain Rectal bleeding Abdominal cramps
Genitourinary:
Weak stream Loss of urine Painful urination Urinary urgency
frequency Foul urine odor Waking at night to urinate Difficulty starting stream
Skin:
Rash Tattoos New growth or moles Change in shape of moles Change in color of moles Discoloring
Lymphatic/Hematologic:
Swollen glands Easily bruised Unexplained bruising Free bladder Neurological:
Headaches Speech difficulties Seizures Dizziness
Memory difficulty Visual disturbance Poor balance
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Name: Date of Birth:
Primary Care Physician:
Who referred you?
PAST MEDICAL HISTORY
Mark the following conditions/diseases that you currently have or have been treated for in the past:
General Medicine
Emphysema / COPD Dialysis
Cancer Type______________
Pneumonia Kidney Infection(s)
Diabetes Type: ____________
Tuberculosis Kidney Stones
HIV / AIDS
Valley Fever Urinary Incontinence
Head / Eyes / Ears / Nose / Throat Gastrointestinal Liver (Hepatic)
Headaches Bowel Incontinence Hepatitis A (Active / Inactive / Unsure) Migraines GERD (Acid Reflux)
Head Injury Gastrointestinal Bleeding Hepatitis B (Active / Inactive / Unsure) Hyperthyroidism Constipation
Hypothyroidism Glaucoma Hepatitis C (Active / Inactive / Unsure)
Cardiovascular / Hematologic Musculoskeletal Neuro-psychosocial Anemia Amputation Alcohol Abuse Bleeding Disorders Bursitis Alzheimer Disease Heart Attack Carpal Tunnel Syndrome Bipolar Disorder
High Blood Pressure Chronic Low Back Pain Depression High Cholesterol Chronic Neck Pain Epilepsy Mitral Valve Prolapse Chronic Joint Pain Prescription Drug Abuse
Murmur Fibromyalgia Multiple Sclerosis Phlebitis Joint Injury Paralysis Poor Circulation Osteoarthritis Peripheral Neuropathy Stroke Osteoporosis Schizophrenia
Coronary Artery Disease Phantom Limb Pain Seizures Pacemaker / Defibrillator Rheumatoid Arthritis Reflex Sympathetic Dystrophy /
CRPS Tennis Elbow Vertebral Compression Fracture
Respiratory Genitourinary / Nephrology Asthma Bladder Infection(s)
Explain any other conditions not listed above:
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Name: Date of Birth:
Primary Care Physician:
Who referred you?
PAST SURGICAL HISTORY
Please indicate any surgical procedures you have had done in the past, including the date, type, and any pertinent details.
I HAVE NEVER HAD ANY SURGICAL PROCEDURES DONE. Spine / Back Surgery Joint Surgery
Discectomy (levels) Ankle/Foot
Laminectomy Shoulder
Spinal fusion (levels) Hip
Spinal cord stimulator Knee
Other
Wrist/Hand
Abdominal Surgery Other
Gallbladder removal Heart Surgery
Appendectomy Valve replacement
Gastric bypass Aneurysm repair Other ......
Stent placement
Female Surgeries Other Surgeries
Caesarean section Hemorrhoid surgery
Hysterectomy Hernia repair
Laparoscopy Thyroidectomy
Ovarian Vascular surgery
Other Other Have you ever had a reaction to anesthesia? Yes No Explain: Has anyone in your family ever had a reaction to anesthesia? Yes No Explain:
LIST ANY OTHER SURGERIES NOT LISTED ABOVE:
Coronary artery bypass
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Name: Date of Birth:
Primary Care Physician:
Who referred you?
FAMILY HISTORY
Other medical problems: I have no significant family medical history. I am adopted (No Medical History Available).
SOCIAL HISTORY
Do you smoke, chew tobacco, or use E-cigarettes? Currently Formerly, quit: ____________ Never used
Alcohol Use:
Do you use illegal drugs? Currently Formerly, what drug: ____________ Never used
Have you ever abused illegal drugs or prescription medications? No Yes, which:
Marital Status: Other ____________________
Genetic/ethnic background/ancestry (Ex. Irish, Middle Eastern, etc.): _________________________________
Are you Working: : __________________________________
Job Description: __________________________ If retired, what type of work did you do? ________________
Highest level of education obtained: Grammar school High school College Post-graduate
Are you on disability? Yes No If yes, since when and why? ___________________________________
Are you pregnant? Yes No Do you have a history of physical, sexual or emotional abuse? Yes No
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Name: Date of Birth:
Primary Care Physician:
Who referred you?
DIET
Do you feel you eat a healthy diet on a daily basis? Yes No
Do you follow a specific dietary lifestyle? Yes No Explain: ____________________________
Have you ever had an eating disorder? No Yes, type:
Do you consume caffeinated beverages? No Yes If yes, how many per day? 1-2 3-4 5+
Do you have any known food or environmental allergies? Yes No
If yes, list sensitivities or intolerances:
Do you have at least 1 bowel movement daily? Yes No
Are you prone to have constipation diarrhea
EXERCISE
Height __________Weight ________
Do you exercise? Yes No If yes, how many days per week 1-2 3-4 5-7
How much time do you exercise on the days you do exercise? 15-30 min 30-60 min 60+ min
Are you involved in any recreational sports or hobbies? Yes No Please list ________
What type of exercise do you enjoy? ________
Do you have specific exercise/fitness goals: Yes No ________
SLEEP
Hours of sleep on average each night: ________
Do you wake up feeling refreshed? Yes No Do you snore? Yes No
Have you ever had a sleep study? Yes No
STRESS/ENERGY
Do you have a lot of stress in your life currently? Yes No
If yes, what is the usual source of the stress?
What is your typical stress level? 1 2 3 4 5 6 7 8 9 10
Are you constantly amped up or jittery? Yes No Are you: easily upset irritable
What is your mid-day energy level? 1 2 3 4 5 6 7 8 9 10
What is your current outlet or strategy to deal with stress? __________________________________________________ __________________________________________________________________________________________________
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Name: Date of Birth:
Primary Care Physician: Who referred you?
NUTRITIONAL SUPPLEMENTS
Please use the table below to list all vitamins, minerals, amino acids, or other supplemental products (meal
replacements, bars, shakes, protein supplements, etc.) you are currently taking.
Name Brand How long have you
taken?
Form (capsule, tablet, liquid,
chewable)
How much do you take at a time?
How many times per
day?
Prescribed by a health professional? (Yes/No; if
yes, by who?)
Ex: Vitamin E
Nature’s Made
6 months Soft gel cap 400 IU 2 times a day
Dr. X
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Name: Date of Birth:
Primary Care Physician: Who referred you?
CURRENT MEDICATIONS Please use the table below to list all medications you are currently taking.
Drug name Dose per pill
Do you take this every
day?
When do you take this during the day?
How many do you take at a time?
How many do you take per
day?
Who prescribes this medication?
Example: Benadryl
25mg Yes/No At bedtime 1 or 2 2 times a day Dr. X
Please indicate which (if any) of the following blood-thinners you are taking:
Aggrenox Coumadin/Warfarin Effient Lovenox Plavix Pletal
Pradaxa Prasugrel Ticlid Other__________________________________________
I AM NOT ON ANY BLOOD THINNING MEDICATIONS
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Name: Date of Birth:
Primary Care Physician:
Who referred you?
ALLERGIES TO MEDICATION
Do you have any known allergies, to medication? Yes No If yes, please list all foods and the reaction:
Medication
Reaction
Example: Penicillin
Rash
Please indicate which (if any) of the following blood-thinners you are taking:
Aggrenox Coumadin/Warfarin Effient Lovenox Plavix
Pradaxa Prasugrel Ticlid Pletal Other
I AM NOT ON ANY BLOOD THINNING MEDICATIONS
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Name: Date of Birth:
Primary Care Physician:
Who referred you?
MEDICAL HISTORY AND CONSENT FOR TREATMENT I certify that the above information is accurate, complete and true.
I authorize Rejuv Medical Southwest and any associates, assistants, and other health care providers it may deem necessary, to treat
my condition. I understand that no warranty or guarantee has been made of a specific result or cure. I agree to actively participate in
my care to maximize its effectiveness.
I give my consent for Rejuv Medical Southwest to retrieve and review my medication history. I understand that this will become part
of my medical record.
I acknowledge that I have had the opportunity to review Rejuv Medical Southwest’s Notice of Privacy Practices, which is displayed
for public inspection at its facility and on its website. This Notice describes how my protected health information may be used and
disclosed, and how I may access my health records.
I authorize the Rejuv Medical Southwest to release my Protected Health Information (medical records) in accordance with its Notice
of Privacy Practices. This includes, but is not limited to, release to my referring physician, primary care physician, and any
physician(s) I may be referred to. I also authorize Rejuv Medical Southwest to release any information required in obtaining
procedure authorization or the processing of any insurance claims.
I understand that Rejuv Medical Southwest will not release my Protected Health Information to any other party (including family)
without my completing a written “Patient Authorization for Use and Disclosure of Protected Health Information” form, available at
its facility and on its website.
In the event that I am asked to provide a urine and/or blood sample, I voluntarily seek laboratory services and hereby consent to
provide a urine and/or blood sample as requested. I have the right to refuse specific tests, but understand this may impact my pain
management treatment. This agreement can be revoked by me at any time with written notification and is valid until revoked.
Signed: __________________________________________________ Date: _________________________________
Parent/Guardian Name (if under 18) _______________________________________________________________________
PAYMENT AND APPOINTMENT POLICY
Copayments / Coinsurance / Deductible: Copayments, coinsurance, and deductibles for clinic visits and procedures are due at the
time of service. If you are unable to make your copayment at the time of service, Rejuv Medical Southwest reserves the right to
reschedule your appointment until a time that you are able to make your copayment. Payment for any outstanding balance is due at
your appointment.
Missed Appointments and Late Arrivals. If you are more than 15 minutes late we may reschedule your appointment. (“Late” means
arriving after the time you are asked to arrive at the clinic.) If you do not show up to your appointment, you will be responsible for a
missed appointment fee. Missed appointments are subject to a $50 charge. These charges are your responsibility and will not be
billed to any insurance carrier.
I understand and agree to the Financial and Appointment Policy.
Signed: __________________________________________________ Date: _________________________________
Parent/Guardian Name (if under 18) ________________________________________________________________________
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE I acknowledge that I have received a copy of the office’s Notice of Privacy Practices.
Signed: __________________________________________________ Date: _________________________________
Parent/Guardian Name (if under 18) ________________________________________________________________________
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