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 PainAnemia / 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 ______