ࡱ> LOK )bjbj 4Ddd!%]]]]]qqq84<q";;;$r]]];;vvv];];vvv;`q0$$$]vv$ #:  Patient Information Sheet Last Name: _______________________________ First Name: _________________________________ MI: _______ Street: ________________________________________________City/State: _____________________ Zip: __________ Main Phone:(_____) ________ - _________Alt Phone: (_____) _________ - _________ SS#:________ - _____ - _________ Sex: (please circle) M F Age: _____ Birth Date: _____ - _____ - _____ Weight: ______ Height: ______ Employer: _________________________________________ Phone: (_______) ________ - _________ Street: ______________________________________ City/State: __________________ Zip: __________ What is your activity level at work? Sitting Standing Walking considerable movement Retired ******Emergency Contact: ___________________ relation____________ Phone:(______) ______ - __________******* *If the insurance holder is someone other than yourself (Parent, Spouse, Guardian or Other) or the patient is under the age of 18, please fill out the information below.* *Last Name: _____________________________ *First Name: ________________________ *MI: _______ *Street: _________________________________ *City/State: ______________________ *Zip: _________ *Phone: (_____) _______ - __________ *Social Security Number: ________ - ______ - _______ * Birthdate: _______ - ________ - ________ *Employer: __________________________________________ *Work Phone: (______) ______ - _______ *Responsible Party (if other than patient) --------- *Relationship to the patient? ___________  How did you hear about us? Newspaper __; Radio __; TV __; Internet/Phone book__; Other __ Patient Referral _____________________________ Physician Referral _______________________________________ Family Physician: ____________________________or Clinic:_________________________ Date Last Seen: __________ _______________________________________________________________________________________________________ What is the reason for your visit today? ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ How long has your problem been present? (please circle) Few days week 2-3 weeks month other__________ How would you describe your pain? Sharp aching throbbing burning shooting numbness pins and needles other________ Have you attempted any treatments to relieve your problem? Yes No If yes, please mark below all that applies: Rest ice heat OTC padding change stretching OTC anti-inflammatory medication (Motrin, Aleve, Tylenol, etc.) Shoe Size: _____ Do you currently or have you ever used foot orthotics/braces? Yes or No If Yes, please describe: ____________________________________________________________________ Please list your current medications: ___________________________ ______________________________ __________________________ ___________________________ ______________________________ __________________________ ___________________________ ______________________________ __________________________ ___________________________ ______________________________ __________________________ ___________________________ ______________________________ __________________________ ___________________________ ______________________________ __________________________ ___________________________ ______________________________ __________________________ Are you currently taking any blood thinners? Yes No if yes, please circle all that may apply: Coumadin Heparin Aspirin(81mg or 325 mg) Plavix Other Are you allergic to ANY medications? Yes No If Yes, please specify___________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Preferred Pharmacy: Please complete the following questions regarding your current and past medical history. Medical History; please circle all that may apply: Cardiovascular: Respiratory: Vascular/Circulation: Neurological: High blood pressure asthma blood clot/deep vein seizures Heart attack bronchitis varicose veins numbness Irregular heart beats emphysema blocked arteries headaches Pacemaker shortness of breath thrombosis stroke Chest pain tuberculosis circulation disorder polio Rheumatic fever pneumonia leg pain muscle weakness Angina collapsed lung phlebitis neuro-muscle disease Angioplasty lung cancer high cholesterol tremor Heart murmur change in memory Open heart/bypass surgery Sciatica Vision: Hearing: Throat: Nose: Impaired vision hearing loss frequent infections sinus/allergies Macular degeneration frequent infections difficulties with speech frequent nose bleeds Cataracts dizziness hoarseness deviated septum Frequent infections loss of balance swollen nodes/glands nasal polyps Glaucoma Gastrointestinal: Genitourinary: Hematological: Integument: Heart burn/reflux renal failure anemia skin rash Ulcer renal dialysis sickle cell disease or trait discolored moles Hepatitis A kidney stone cancer/leukemia Psoriasis Abdominal pain frequent bladder infections blood transfusions Eczema Gallbladder problems frequent urination skin cancer Hepatitis B gonorrhea hives Liver disorder syphilis skin growth Colitis Chlamydia Endocrine: Warts Hepatitis C HIV Thyroid disease Loss of appetite herpes Diabetes, Type 1 or 2 Excessive thirst Ovarian Cancer Average BSL________ Prostrate Cancer Last A1C_______ Muskoskeletal: Do you have/have you had any of the following: Arthritis/degenerative joint disease rheumatoid arthritis gout back pain hip pain knee pain Frequent muscle/tendon/pain Psychiatric - Do you have: Depression anxious/agitation memory loss concentration difficulties suicidal nervousness Phobias bipolar disease feeling of worthlessness/low self esteem Immunology Do you have: HIV Frequent infections/weak immune system chronic fatigue syndrome/Ebstein Barr Surgical History Please list ALL surgical procedures you have had, and approximate month/year: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Have you had any Joint replacements: hip knee ankle spine shoulder other Please indicate location(Left or Right)_____________________________________________________________ Please list any complications from surgery including healing or adverse reactions to anesthesia: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Do you: Smoke Yes No packs per day_____ Drink alcohol Yes No drinks per day______ or Occasional Please indicate if any of your immediate family members have the following: Mother/Father/Siblings High blood pressure - ___________________________CVA/Stroke - _________________________________ Cancer (Type)-_________________________________Diabetes - ____________________________________ Circulation problems-_____________________________Please specify if other -__________________________ I have answered these questions truthfully and to the best of my knowledge. Signature_____________________________________________________________Date: _________________     PAGE  PAGE 2  &  ? 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