Six Corners Sameday Surgery

First Name

Middle Name

Last Name

Sex

Male Female

Marital status

Date of Birth

Social Security Number

Patients Address

City

State

Zip

Home Phone

Mobile Phone

Referred by

Primary Care Physician

Primary Care Physician Phone

Pharmacy

Pharmacy Phone

Pharmacy Address

Patient Employer/School Information

Employer School

Occupation

Employer/School Phone

Employer/School Address

City

State

Zip

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Relation to Patient

Primary Health Insurance

Insurance Company

Plan

Plan Number

Group Number

Insured’s Employer/School

Insured’s Name (as it appears on insurance card or ID)

Insured’s Address

City

State

Zip

Insured’s Social Security Number

Insured’s Birthdate

Relation to Patient

Insured’s Phone Number

Secondary Health Insurance

Insurance Company

Plan

Plan Number

Group Number

Insured’s Employer/School

Insured’s Name (as it appears on insurance card or ID)

Insured’s Social Security Number

Relation to Patient

Insured’s Phone Number

Responsible Party

Billing Name (if other than patient)

Phone

Relation to Patient

Address

City

State

Zip

Reason for Visit

What brings you to the office today?

When did the problem begin?

Where is the problem located?

Left-side Right-side Both

What event or incident is this problem related to?

Work Accident Car Accident Other:

Pain Assessment

Indicate your level of pain on a scale of 1 - 10. ( 10 = worst pain imaginable )

1 2 3 4 5 6 7 8 9 10

What is the Maximum Number of stairs that you can climb?

None A Few Steps 1/2 Flight 1 Flight 2 or more Flights

( 0 = No pain or limitation at all , 10 = The worst possible pain or limitaion that you could imaginable )

How bad your pain today?

0 1 2 3 4 5 6 7 8 9 10

How bad is the pain at the worst its ever been?

0 1 2 3 4 5 6 7 8 9 10

How bad is the pain at the best its ever been?

0 1 2 3 4 5 6 7 8 9 10

Does the pain interfere with your lifestyle?

0 1 2 3 4 5 6 7 8 9 10

Does the pain interfere with your work?

0 1 2 3 4 5 6 7 8 9 10

Do you have pain lying in bed?

0 1 2 3 4 5 6 7 8 9 10

Check the symptoms that best describe your problem.

Stiffness Pain Instabillity Swelling Numbness Other

Are your symptoms getting...

Better Gradually Better Rapidly Worse Gradually Worse Rapidly

What improves your symptoms?

Rest Ice Heat Motrin/ Aleve Other

Check the symptoms that best describe your problem.

Activity Cold Other

Have you or are you planning to apply for disability?

Yes No

Is there a lawsuit or litigation pending in relation to your pain?

Yes No

Please describe any previous treatment and care you have received for this problem.

For Spine Patients Only

For how long you had back pain?

Year

Month

Weeks

For how long you had leg pain?

Years

Months

Weeks

Pain Intensity

I can tolerate pain without taking painkiller.

The pain is bad, but I manage without taking painkillers.

Painkillers give me complete relief from pain.

Painkillers give me moderate relief from pain.

Painkillers give me very little relief from pain.

Painkillers have no effect on the pain, and I do not use them.

Personal Care (Washing,dressing,etc.)

I can look after myself normally without causing extra pain.

I can look after myself normally ,But it causing extra pain.

It is painful to look after myself, and I am slow and careful.

I nedd some help, but I can manage most of my personal care.

I nedd help every day in most aspects of self care.

I do not get dressed, wash with difficulty, and stay in bed.

Liffting

I can lift heavy weights without extra pain.

I can lift heavy weights, but it gives me extra pain.

Pain prevents me from liffting heavy weights off floor,but I can manage if they are conveniently positioned.e.g,on a table.

Pain prevents me from liffting heavy weights, but i can manage light medium weights If they are convenlently positioned.

I can lift only very light weights.

I can not lift or carry anything at all.

Walking

Pain does not prevent me from walking any distance.

Pain prevents me from walking more than 1 mile.

Pain prevents me from walking more than 30 minutes.

Pain prevents me from walking more than 10 minutes.

I can only walk using a cane or cruntches.

I am in bed most of the time and have to crawl to the toilet.

Sitting

I can sit In any chair as long as i like.

I can only sit in my favourite chair for as long as I like.

Pain prevents me from sitting for more than 1 hour.

Pain prevents me from sitting for more than 30 minutes.

Pain prevents me from sitting for more than 10 minutes.

Pain prevents me from sitting at all.

Standing

I can stand as long as I want without extra pain.

I can stand as long as I want, but It gives me extra pain.

I can stand as long as I want without extra pain.

I can stand as long as I want, but it gives me extra pain.

Pain prevents me from standing for more than 1 hour.

Pain prevents me from standing for more than 30 miniutes.

Pain prevents me from standing for more than 10 miniutes.

Pain prevents me form standing at all.

Sleeping

Pain does not prevent me from sleeping well.

I can sleep well only by using tablets.

Even when I take tablets,I have less than 6 hours of sleep.

Even when I take tablets,I have less than 4 hours of sleep.

Even when I take tablets,I have less than 2 hours of sleep.

Pain prevents me from sleeping at all.

Sex life

My sex life is normal and causes no extra pain.

My Sex life is normal but causes some extra pain.

My sex life is nearly normal, but it is very painful.

My sex life is nearly restricted by pain.

My Sex life is nearly absent because my pain.

Pain prevents me from having any sex life at all.

Social Life

My social life is normal and gives me no extra pain.

My social life is normal but Increases the degree of pain.

Pain has no significant effect on my social life, apart from limmiting my more energetic intrests,e.g dancing,etc.

Pain has restricated my social life and do not go cut as often.

Pain has restricated my social life to being at my home.

I have no social life because of pain.

Travelling

I can travel anywhere without having pain.

I can travel anywhere, but It gives me extra pain.

Pain is bad, but I can manage journeys over 2 hours.

Pain restricts me to journeys less than 1 hour in duration.

Pain restricts me to short necessary journeys under 30 minutes.

Pain prevents me form tavelling except to the doctor or hospital.

Lifestyle Factors

Have you ever smoked?

Yes No

# of years

# packs/day

Do you smoke now?

Yes No

# packs/day

Do you use recreational drugs?

Yes No

types?

# times/week

How much alcohol do you drink per week?

# drinks/week

How much cafeine do you drink per day?

# times/week

Hospitalizations & Surgeries

Reason

Reason Date

Reason

Reason Date

Reason

Reason Date

Reason

Reason Date

Current Medications

Are you currently taking any blood thinners?

Yes No

What medications are you currently taking?

Name

Dosage

Frequency

Name

Dosage

Frequency

Name

Dosage

Frequency

Allergies

Are you allergic to any of the following?

Adhesive Tape

Barbiturates (Sleeping Pills)

Codeine

Latex

Local Anesthetics

Antibiotics

Aspirin

Sulfa

Iodine

Do you have any other allergies?

Name

Reaction

Name

Reaction

Past History

Have you ever had any of the following?

alcoholism

allergies

anemia

anxietydisorder

arthritis

asthma

aids_hiv

backproblems

bleedingdisorder

blooddisease

bloodtransfusion

cancer

diabetes

depression

earproblems

eatingdisorder

epilepsy

glaucoma

gout

heartdisease

heartproblems

hepatitisabc

highbloodpressure

highcholesterol

jointdisorder

kidneydisorder

liverdisorder

lungdisease

measles

migraines

osteoporosis

pneumonia

polio

rheumaticfever

stroke

skindisorder

stomachulcer

thyroiddisorder

tuberculosis

venerealdisease

Family History

Has anyone in your family ever had any of the following conditions?

Alcoholism

Allergies

Alzheimer’s

Anemia

Anxiety

Arthritis

Asthma

AIDS/HIV

Bleeding Disorder

Blood Disorder

Cancer

Depression

Diabetes

Epilepsy

Genetic Disorder

Glaucoma

Heart Disease

Hepatitis

High Cholesterol

High Blood Pressure

Joint Disorder

Kidney Disease

Liver Disorder

Lung Disease

Migraines

Psychiatric Disorders

Osteoporosis

Stroke

Substance Abuse

Thyroid Disorder

Details:

Women Only

Are you pregnant?

Yes No

Are you breastfeeding?

Yes No

Other Notes

Note:

General

Chills

Dizziness

Fainting

Fever

Hair Loss

Hair Growth – Excessive

Night Sweats

Sleeping Problems

Thirst - Excessive

Weight Gain

Weight Loss

Gastrointestinal

Appetite Gain

Appetite Loss

Bloating

Bowel Changes

Constipation

Gas

Indigestion

Intestinal Disorder

Lactose Intolerance

Nausea

Rectal Bleeding

Stomach Pain

Vomiting

Vomiting Blood

ENT

Bleeding Gums

Blurred Vision

Crossed Eyes

DifficultyEwallowing

Double Vision

Earaches

Ear Discharge

Hay Fever

Hoarseness

Hearing Loss

Nose-Bleeds

Persistent Cough

Persistent Runny Nose

Recurring Sore Throat

Ringing in Ears

Sinus Problems

Vision Halos

Musculoskeletal

Back Pain

Carpal Tunnel Syndrome

Joint Pain

Joint Swelling

Neck Pain

Shoulder Pain

Men Only

Erection Difficulties

Lump in Testicles

Penile Discharge

Sore on Penis

Mental Health

Anxiety

Depression

Loss of Interest

Feeling Hopeless

Hearing Voices

Marital Problems

Panic Attacks

Trouble Concentrating

Suicide –Thoughts/Attempts

Genitourinary

Blood in Urine

Lack of Bladder Control

Frequent Urination

Painful Urination

Respiratory

Coughing

Coughing Up Blood

Shortness of Breath

Wheezing

Women Only

Abnormal Pap Smear

Bleeding between Periods

Breast Lump

Extreme Menstrual Pain

Hot Flashes

Nipple Discharge

Painful Intercourse

Vaginal Discharge

Skin

Acne

Bruise Easily

Changes in Moles

Chills

Dry / Sensitive Skin

Eczema

Hives

Itching

Rash

Scars

Sores That Won’t Heal

Neurological

Coordination Problems

Convulsions

Difficulty Walking

Learning Disabilities

Light-headedness

Memory Loss

Numbness / Tingling

Paralysis

Seizures

Speech Problems

Tremors

Cardiovascular

Chest Pains

Irregular Heart Beat

Circulation Problems

Heart Palpitations

Rapid Heartbeat

Swelling of Ankles

Varicose Veins

Other Symptoms

Details:

Health Exams & Procedures

Please check and date the last time you had each exam or procedure performed.

Cholesterol Test

Colonoscopy

CT/CAT Scan

EKG

Echocardiogram

MRI

Physical Exam

Cardiac Stress Test

Ultra Sound

Immunizations

Please check and date all immunizations you have had.

Hepatitis A

Hepatitis B (Series of 3)

HPV Vaccine

Influenza(Flu Shot)

Meningitis

MMR (Measles,Mumps, Rubella)

Pneumonia

Polio

Tetanus

Go back
Save & Continue
Are you a robot? What is 2 + 2 =
Saved! Your Form ID is: Copy

Patient Registration Form

Patient Employer/School Information

Emergency Contact Information

Primary Health Insurance

Secondary Health Insurance

Responsible Party

Reason for Visit

Pain Assessment

( 0 = No pain or limitation at all , 10 = The worst possible pain or limitaion that you could imaginable )

For Spine Patients Only

Lifestyle Factors

Hospitalizations & Surgeries

Current Medications

Allergies

Past History

Family History

Women Only

Other Notes

General

Gastrointestinal

ENT

Musculoskeletal

Men Only

Mental Health

Genitourinary

Respiratory

Women Only

Skin

Neurological

Cardiovascular

Other Symptoms

Health Exams & Procedures

Immunizations