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New Patient Questionnaire |
To save you time please print and bring into our office on your first visit. |
Name __________________________ |
Date __________________________ |
Please describe any problems you are currently experiencing or have experienced in the past to help us get a better understanding of your health history. For example, if you now, or as a child, frequently were ill with ear infections please write that in the ears/noise/throat section below. Again please be as detailed as possible as this form is VERY IMPORTANT to us. We need to know as much about you as possible in order to properly evaluate and treat your condition. 1. WHOLE BODY HEAD:(concussions, stroke, headaches, dizziness, etc.) EARS/NOSE/THROAT: (ear infections, inner ear problems, nose bleeds, frequent strep infection difficulty swallowing, loss of hearing, smelling or taste etc.) EYES:(corrective lenses, dryness, double/blurry vision etc.) THYROID: (hyper/hypothyroidism? Medication for this? ARMS/LEGS: pains, skin disorders, abnormal weakness, loss of Iimbs/fingers/toes, briefly explain how loss occurred, etc.) ABDOMINAL/REPRODUCTIVE AREA:(nausea, ulcers, kidney stones, ovarian cancer, prostate problems, diabetes, bladder control any cancers, etc.) LUNG/HEART:(difficulties breathing, asthma, heart attacks, angina, stroke, rapid/slow heart rate, pacemaker, etc.) BLOOD: (anemia, etc) |
For the next several questions please answer briefly and give the dates each began to the best of your knowledge and if you can think of what contributed to it. 1. Any history of fainting/loss of consciousness? 2. Noticeable changes in your handwriting? 3. Changes in sexual functions? 4. Are you more irritable? 5. Episodes of depression or anxiety? 6. Problems with equilibrium, loss of balance, tripping, dropping things, etc? 7. Difficulty in scanning pages while you read a book? 8. Difficulty adding or subtracting? 9. Difficulty moving your eyes? Or double vision? 10. Difficulty expressing what you would like to say? 11. Any changes in speech? 12. Any changes in sensations? 13. Any changes in memory? 14. Any changes in hearing? 15. Excess dryness or wetness of the eyes or nose? |
MEDICATIONS What type? Prescription or over the counter? What are they for and who presribed them? PREVIOUS TREATMENTS FOR PRESENT PROBLEM Please list any other Doctors. Dates of X-rays, MRI, CAT scans, Bone scans, ect |
DAILY HABITS: (Please give short answers. For example, for Coffee if you drink 2 cups put 2 cups/day Coffee Soft Drinks (Diet or regular) Alcohol Drugs Cigarettes Type of bed you sleep on (Water, firm, soft) Type of pillow? (Large, small old/new) FULL DESCRIPTION (DETAILED OF WORK ACTIVITIES What do you do? What are your duties? How many hours per week do you work? Do you do a lot of twisting at work? Surgeries (knee replacement, hip replacement, laminectomies, disc surgery, Appendectomy, etc) |
Please initial next to each item and sign the bottom. Thank you. ____ I do not have a pacemaker. ____ I do not have arrhythmia. ____ I am not on any heart regulating medication. ____I am not pregnant. Print Name____________________________ Signature______________________________ Date________ |
Fibromyalgia |