utah neurological clinicutah neutah neurological
Post on 21-Jan-2022
11 Views
Preview:
TRANSCRIPT
Date: _________________________________________________________
Referring Physician: ___________________________________________
Utah Neurological ClinicUtah Neurological ClinicUtah Neurological ClinicUtah Neurological Clinic
1055 North 300 West, Suite 400
Provo, Utah 84604
Telephone: (801) 357-7404
PLEASE FILL OUT COMPLETELY. ACCURATE INFORMATION HELPS YOU.
Patient Name: ____________________________________________
Birthday: _________________________________________________
Present Age: _____________________________________________
Right or Left Handed: _____________________________________
1. Do you have a Latex allergy? Yes ________ No ________Do you have a Latex allergy? Yes ________ No ________Do you have a Latex allergy? Yes ________ No ________Do you have a Latex allergy? Yes ________ No ________
2. What is/are your chief area(s) of pain? Please check all those that apply.
Head ______ Neck ______ Upper back ______ Lower back ______ Shoulder(s) ______
Arm(s) ______ Buttocks ______ Leg(s) ______
3. Date of injury ____________ Was it work related? ________ Was it auto related? ________
Were you wearing a seat belt? _______ Please describe your injury __________________________________
__________________________________________________________________________________________________
4. How frequently do you experience pain? Please circle one.
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
5. Are you experiencing any muscle weakness? Yes _____ No _____ Where? _______________________
6. Are you experiencing any numbness or pain? Yes _____ No _____ Where? _______________________
7. Are you having any headaches caused by this injury? Yes _____ No _____
How often? _____________ Where are the headaches located? Please check all of those that apply.
Front _____ Back _____ Top _____ Side _____ Behind the eyes _____
8. Have you had any of the problems below? Please check all those that apply.
Numbness or tingling in: Arm(s) ____ Leg(s) ____ Face ____ Difficulty walking ____
Poor Coordination ____ Neck pain ____ Back pain ____ Arm pain ____ Leg pain ____ Tremor ____
Stroke or CVA ____
9. Is there anything that alleviates the problem? Please describe ______________________________________
__________________________________________________________________________________________________
10. Is there anything that aggravates the problem? Please describe ___________________________________
__________________________________________________________________________________________________
2
Laboratory DataLaboratory DataLaboratory DataLaboratory Data
11. Have any tests been performed to evaluate this problem? Yes _____ No _____
Please indicate if you have had any of the following studies and the results as you understand them.
STUDYSTUDYSTUDYSTUDY WHENWHENWHENWHEN WHEREWHEREWHEREWHERE RESULTSRESULTSRESULTSRESULTS
Plain X-rays
MRI scan
Bone scan
Discogram
CT/Myelogram
NCV/EMG
Medical HistoryMedical HistoryMedical HistoryMedical History
12. Do you have, or have you been treated for any medical conditions? Please check all those that apply.
Lung/Breathing problems yes no Heart disease/Myocardial infarction yes no
High Blood Pressure/Hypertension yes no Liver Disease yes no
Kidney Disease yes no Thyroid Disease yes no
Diabetes yes no Cancer yes no
Stomach Problems yes no Urinary/Bladder yes no
Infectious Disease yes no Arthritis yes no
Sinus Disease yes no Allergies yes no
Dental/TMJ yes no Headache yes no
Seizure/Epilepsy yes no Stroke Yes no
Multiple Sclerosis yes no Parkinson’s Disease yes no
Depression/Anxiety yes no Psychiatric Disorder yes no
Head Injury yes no Spine Injury yes no
Mental Retardation yes no Learning Disability yes no
Surgical HistorySurgical HistorySurgical HistorySurgical History
13. Please list below, in order (most recent first), your surgical history.
DATEDATEDATEDATE OPERATIONOPERATIONOPERATIONOPERATION BY WHOMBY WHOMBY WHOMBY WHOM WHEREWHEREWHEREWHERE COMPLICATIONSCOMPLICATIONSCOMPLICATIONSCOMPLICATIONS
3
MedicationsMedicationsMedicationsMedications
14. Please list the medications you are taking for pain: __________________________________________________Other medications: ________________________________________________________________________________
AllergiesAllergiesAllergiesAllergies
15. Are you allergic to any medications? Please list: ____________________________________________________
HabitsHabitsHabitsHabits
16. Do you smoke? Yes ____ No ____ How many years? _______ How many packs per day?_______
17. Do you drink alcoholic beverages? Yes ____ No ____
Family HistoryFamily HistoryFamily HistoryFamily History
18. Has anyone in your family had, or is anyone being treated for the following? Please check anddescribe.
Yes/No Who? Yes/No Who?
Epilepsy/Seizure Yes No __________________ Parkinson’s Disease Yes No __________________
Stroke Yes No __________________ Migraine Headaches Yes No __________________
Paralysis Yes No __________________ Heart Disease Yes No __________________
Nerve Disease/numbness Yes No __________________ Diabetes Yes No __________________
Muscle disease/weakness Yes No __________________ Hypertension Yes No __________________
Alzheimer’s/dementia Yes No __________________ Cancer Yes No __________________
Alcoholism Yes No __________________ Mental Retardation Yes No __________________
Back/Neck pain Yes No __________________ Arthritis Yes No __________________
19. Has anyone in your family had symptoms like yours? Please describe: ________________________________
_________________________________________________________________________________________________
Social HistorySocial HistorySocial HistorySocial History
20. Occupation: __________________________ Are you working?________ Last date worked: _______________
21. Please note your physical work requirements: Heavy ____ Moderate ____ Light ____ Sedentary ____
22. What is your marital status? Married ____ Single ____ Divorced ____ Widowed ____ Separated ____
23. Do you have any children? Yes ____ No ____ How many? ______
4
Review of SystemsReview of SystemsReview of SystemsReview of Systems
24. Have you experienced any of the following in the last six months? (please check those that apply):
CONSTITUTIONAL Date
Good general health lately Yes No
Recent weight change Yes No
Fever Yes No
Fatigue Yes No
Headaches Yes No
EYES
Eye disease or injury Yes No
Wear glasses/contact lenses Yes No
Blurred or double vision Yes No
Glaucoma Yes No
ENT
Hearing loss Yes No
Ringing in the ears Yes No
Earaches or drainage Yes No
Sinus Problems Yes No
Nose bleeds Yes No
Mouth sores Yes No
Bleeding gums Yes No
Bad breath or bad taste Yes No
Sore throat or voice change Yes No
Swollen glands in neck Yes No
CARDIOVASCULAR
Heart trouble Yes No
Chest pains Yes No
Sudden heart beat changes Yes No
Swelling of feet, ankles or hands Yes No
RESPIRATORY
Frequent coughing Yes No
Spitting up blood Yes No
Shortness of breath Yes No
Asthma or wheezing Yes No
GASTROINTESTINAL
Loss of appetite Yes No
Change in bowel movements Yes No
Nausea or vomiting Yes No
Frequent diarrhea Yes No
Painful bowel movements
or constipation Yes No
Blood in stool Yes No
Stomach pain Yes No
Loss of taste Yes No
Difficulty swallowing Yes No
GENITOURINARY
Frequent urination Yes No
Burning or painful urination Yes No
Blood in urine Yes No
Change of force of strain
when urinating Yes No
Incontinence or dribbling Yes No
Kidney stones Yes No
Male - testicle pain Yes No
GENITOURINARY (cont) Date
Female
- pain w/periods Yes No
- irregular periods Yes No
- vaginal discharge Yes No
- # pregnancies _______ # miscarriages _______
- date of last pap smear ______________________
- findings of last pap smear ” Normal ” Abnormal
MUSCULOSKELETAL
Joint pain Yes No
Joint stiffness or swelling Yes No
Weakness of muscles or joints Yes No
Muscle pain or cramps Yes No
Back pain Yes No
Cold extremities Yes No
Difficulty in walking Yes No
SKIN
Rash or itching Yes No
Change in skin color Yes No
Change in hair or nails Yes No
Varicose veins Yes No
Breast pain Yes No
Breast lump Yes No
Breast discharge Yes No
NEUROLOGICAL
Frequent or recurring headaches Yes No
Lightheaded or dizzy Yes No
Convulsions or seizures Yes No
Numbness or tingling sensations Yes No
Tremors Yes No
Paralysis Yes No
Stroke Yes No
PSYCHIATRIC
Memory loss or confusion Yes No
Nervousness Yes No
Depression Yes No
Sleep problems Yes No
ENDOCRINE
Glandular or hormone problem Yes No
Thyroid disease Yes No
Excessive thirst or urination Yes No
Heat or cold intolerance Yes No
Dry skin Yes No
Change in hat or glove size Yes No
HEMATOLOGICAL/LYMPHATIC
Slow to heal after cuts Yes No
Easily bruising or bleeding Yes No
Anemia Yes No
Phlebitis Yes No
Past transfusion Yes No
Enlarged glands Yes No
5
Using the symbols below, please mark the areas on your body where you feel the described sensation. Please
include all affected areas.
Aching Numbness Pins & Needles Burning Stabbing Other
•• = = = + + + X X X //// ••
FRONT BACK
Where is your pain the worst? Please check those that apply.
Arms and Neck Equally
Arms Mostly
Neck Mostly
Legs and Back Equally
Legs Mostly
Back Mostly
6
25. Do you have a Workers’ Compensation hearing scheduled? _______ When _______
26. Is an attorney helping you with respect to your injury? __________________________________________
27. Are you being compensated for lost wages? ___________________________________________________
28. Relative to your current problems, have you been pleased with the medical treatment you have
received up to this time? _________________________________________________________
29. Please list any limitations to your normal activities that you are currently experiencing:
______________________________________________________________________________________________
______________________________________________________________________________________________
30. What do you wish to accomplish with today’s visit: _____________________________________________
______________________________________________________________________________________________
I attest that the information noted above currently represents my symptoms and medical history.
_________________________________________________________ __________________________________
Signature Date
_________________________________________________________ __________________________________
Physician Signature Date
Patient info form 031607
top related