Cherry Health Centerphone:(417)869-2000

Cherry Health Centerphone:(417)869-2000

607 W Battlefield, Springfield MO 65807 fax:(417)881-1850

Patient Name: / Date of Birth: / Sex:
Address:
City: / State: / ZIP:
Email: / Phone:
Marital Status: Married / Single / Separated / Divorced / Widowed/Widower
Social Security #: / Ethnicity:
Family Doctor: / Race:
Primary Insurance: / Effective Date:
Policy Number: / Group Number:
Secondary Insurance: / Effective Date:
Policy Number: / Group Number:
Tertiary Insurance: / Effective Date:
Policy Number: / Group Number:
Emergency Contact: / Relationship:
Phone Number:

Any other HIPAA contacts:

NameRelationshipPhone Number

HIPAA: Any Aspect / Financial Only / Health Only / None

May we leave you a voicemail? YES / NO

CURRENT MEDICATIONS:

NameDosageFrequency

DRUG / CHEMICAL / LATEX / IODINE ALLERGIES:

______

SOCIAL HISTORY:

Alcohol Usage: NONE / LIGHT / MODERATE / HEAVY

Drug Usage: NONE / LIGHT / MODERATE / HEAVY

Tobacco Usage: NONE / LIGHT / MODERATE / HEAVY

Exercise: NEVER / SELDOM / OCCASIONAL / REGULAR

PAST SURGICAL HISTORY:

Past Surgery: Appendectomy / Heart / Hysterectomy / Lower Back /

Mastectomy / Neck / Tonsillectomy / Other: ______

AREA OF CHIEF COMPLAINT: ______

When did your symptoms begin? ______

What caused your symptoms to begin? ______

Was your pain the result of a work injury or auto accident? YES / NO

Is there an open case? YES / NO

Did the pain begin gradually or suddenly? ______

In the past 24 hours, what is your average pain on a scale of 1-10?___

How would you describe the pain? (circle all that apply):

STABBING / DULL ACHE / SHARP / DEEP ACHE / THROBBING / TINGLING/ Other: ______

Is the pain constant or intermittent? ______

Does the pain or numbness radiate into your arms or legs?______

How far?______

Is it getting better, worse, or staying about the same?______

What causes the pain to worsen?______

What helps the pain to lessen?______

Have your tried any of these for this pain: Physical Therapy / Chiropractic / Injections / Ice / Heat / NSAIDS / Tylenol / Surgery / Other:______

Does the pain wake you up at night? YES / NO

Does the pain get so severe that it causes fever, redness, shaking, or nausea? YES / NO

Have you had an X-ray or MRI in the last six months? YES / NO

When:______Where: ______

MEDICAL / FAMILY HISTORY: please specify: S=Self / M=Mother / F=Father

AIDS/HIV/ARC / Diabetes / Neck Pain
Anemia / Dislocated Joints / Nervousness
Arthritis / Epilepsy / Numbness
Asthma / Degenerative Disc Disease / Osteoporosis
Back Pain / Headaches / Poor Circulation
Bladder Trouble / Heart Trouble (A-fib, CHF) / Hepatitis
Bone Fracture / High Blood Pressure / Muscular Dystrophy
Cancer / Kidney Disorder / Rheumatism
Chest Pain / Bowel Control Loss / Serious Injury
Concussion / Menstrual Cramps / Sinus Trouble
Convulsions / Multiple Sclerosis / Tuberculosis
Indigestion / Other:______

I, ______, hereby consent and state my preference to have my physician, ______, and other staff at Cherry Health Center communicate with me by email or standard SMT/text messaging, in addition to or to replace leaving phone messages, regarding various aspects of my health care, which may include, but shall not be limited to, test results, appointments, and billing. I understand that email and standard SMS/text messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS/text messaging regarding my medical care might be intercepted and read by a third party.

I give my permission to leave both appointment reminders AND my private health information at the following (please fill in the ones that you agree to):

Phone number ______

Email ______

Text ______

I give permission to contact me, relative to appointment REMINDERS ONLY, by the following methods (please fill in the ones that you agree to):

Phone number ______

Email ______

Text ______

______

Patient SignatureDate______

Witness / CHC Staff

Patient Name:______DOB:______

Patient Initials ______