New Patient / New Problem Form

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New Patient / New Problem FORM
Dr. Cummings
Name: ______________________________________________________________ Date: _______________
Age: ____ Birthdate:____/_____/________ Occupation:__________________________________________
Current work status:
Regular duty
Light Duty Not working due to problem Retired
Student
Unemployed
Who referred you to us? ________________________________
Primary Medical Doctor: _____________________ Primary Doctor Phone: __________________________
Primary Doctor’s Address: __________________________________________________________________
List any other doctors you see on a regular basis (Cardiology, Pulmonology, Neurology, Rheumatology, etc.)
_______________________________________________________________________________________
_______________________________________________________________________________________
Yes
No
Do you have an Advanced Care Plan (Such as a Living Will)?
Please explain your problem in one sentence ________________________________________________
_______________________________________________________________________________________
Location of symptoms  Left
Right
Both
When did symptoms start? DATE (if known) ________ OR (Days__) (Weeks ___) (Months___ ) (Years___)
What are your expectations today?
 Explanation or Diagnosis
Tests
Medicines
Therapy
Injection
Surgery
 Other: _____________________________________________________________________________
Have you had Medical treatment/tests for this condition in the past? Yes
No
If Yes, what Doctor treated you for this condition and what was done? ________________________
______________________________________________________
X-Rays? Where? _____________  MRI? Where? __________ CT Scan? Where? _________
How did your problem start? (Check the ONE that best describes how your problem started):
 NO INJURY- onset was Gradual
Sudden
Why do you think it started? ____________
 INJURY Accident
Sport
Date of injury ____________ Sport? ______________________
 WORK RELATED Date of Injury/Pain _____________ How? ______________________
 Worker’s Comp
Yes
No
 AUTO ACCIDENT Date___________________
Yes
No
Attorney involved with this problem?
Pain Severity: On a scale of 0-10 (0=none; 10=worst imaginable pain) how severe is your pain? (Circle one)
0
1
2
3
4
5
6
7
8
9
10
1

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00 votes

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