PATIENT INFORMATION Patinfo

PATIENT INFORMATION patinfo.doc 9/2014

Name: ______Date: ______Marital Status: ____ Sex: ___

Address: ______City: ______Zip: ______

Home phone: ______Work phone: ______

Cell phone:______E-mail:______

Date of birth: ______Age: ____ S.S. #: ______Occupation: ______

Employer’s name & address: ______

Spouse’s name: ______Spouse’s work #: ______

Spouse’s employer name & address: ______

PERSON RESPONSIBLE FOR BILL (if other than above)

Name:______Relationship:______Home phone:______

Address (if other

than above):______Work phone:______

Employer name & address:______Position:______

INSURANCE INFORMATION

Insurance Company:______Insured’s name:______

ID#:______Insured’s DOB:______

EMERGENCY CONTACT (if not listed above)

Name & address:______

Relationship: ______Home phone: ______

Work Cell

Phone: ______Phone:______

If the patient is a full-time college student, what school? ______

What was the date he/she was first enrolled (month/year)? :______

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patinfo.doc 9/2014

Patient:______Personal Health Information (includes ROS)

This is important for both our records and your treatment

Please check all that apply to you:

Cardiovascular: ( ) heart disease ( )high blood pressure ( ) heart attack

( ) stroke () TIA ( ) PAD/PVD ( ) intermittent calf/thigh pain while walking

Endocrine/glands:( ) change in appetite ( ) gout ( ) thyroid disease ( ) diabetes

( ) unexplained weight loss

Head/Eyes/Ears/Nose/Throat: ( ) migraines ( ) recurrent headaches ( ) nasal polyps

( ) glasses ( ) hard of hearing ( ) poor balance ( )difficulty swallowing

Gastrointestinal: ( ) ulcers () IBS ( ) colon cancer

Genitourinary: ( ) PID ( ) prostate cancer ( ) kidney disease

Circulation/Blood/lymphatic: ( ) anemia - iron loss ( ) anemia - sickle cell

( ) lymphedema ( ) varicose veins ( ) hepatitis - (type:___)

Dermatologic/Skin: ( ) psoriasis ( ) eczema ( ) dry skin ( ) skin cancer

Muscle/bone: ( ) arthritis ( ) breast cancer ( ) osteoporosis ( ) low back/hip pain

( ) artificial joint(s)

Nerves/Neurological: ( ) MS ( ) spina bifida ( ) CP ( ) drop-foot ( ) neuropathy - numb

( ) spinal stenosis ( ) neuropathy - pain

Respiratory: ( ) asthma ( ) emphysema ( ) COPD ( ) shortness of breath with exertion

Is there anything else that we may not have listed here? ( )No ( )Yes______

Height: ______Weight: ______Shoe size: ______

Medicines currently taken: ______

______

______

Any allergies to medications: ( )none ( )sulfa ( )penicillin ( )codeine ( )IV iodine

( ) other:______

Please list any hospitalizations/surgeries in the past 2 years______

Who is your family doctor?______Where is the office?______

Phone #: ______When did you last see this doctor? ______

How did you FIRST hear about this office? ( ) planbook ( ) Kiwanis ( ) family ( ) Angie’s List

( ) Yellow Book ( ) Yellow Pages ( ) TaiZen ( ) physician referral ( ) Best of LI

( ) Facebook ( ) Internet ( ) friend:______( ) other:______

Briefly, please tell us why you’re here:______

______

______

How long has this been a problem?______

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Patient: ______patinfo.doc 9/2014

Do you have any artificial joints or implants? [ ] No [ ] Yes What? ______

Do you have a pacemaker? [ ] No [ ] Yes

If there anything else important we may have missed, please tell us: ______

______

______

FAMILY HISTORY: Mother: [ ] living [ ] deceased- cause of death______

Father: [ ] living [ ] deceased- cause of death______

# of brothers living ______deceased ______cause of death______

# of sisters living ______deceased ______cause of death ______

Is there any blood relative who has/had:

[ ] heart disease [ ] diabetes [ ] bleeding disorder [ ] high arches/insteps

[ ] nerve disorder [ ] circulation problems [ ] problems with anesthesia

PERSONAL/SOCIAL HISTORY:

Do you smoke? [ ] No [ ] Yes [ ] Former

Do you drink alcohol or beer? [ ] No [ ] Yes- __socially ___weekly ___daily

Do you use recreational drugs? [ ] No [ ] Yes

About your job/lifestyle: [ ] inactive [ ] on feet a little [ ] on feet a lot

Sports participation: [ ] none [ ] mild (once a week) [ ] active

Which sport(s)?______

Please indicate what you’d like to be called: [ ] first name [ ] Mr/Mrs/Ms/Dr

[ ] nickname: ______

For women only: Are you pregnant? [ ] yes [ ] no [ ] maybe

That’s about it. Please read and sign the following:

I understand the above questions and have answered them to the best of my knowledge. I give Dr. Hickey/Dr. Montag, and any assistant he may deem necessary, permission to treat me (or, if this applies, my dependent child/children).

______

Patient’s/guardian’s signature Date

THANKS! Pg 3/3