Patient Intake And History Form - New West Sports

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NEW WEST SPORTS MEDICINE & ORTHOPAEDIC SURGERY, PC
PATIENT INTAKE AND HISTORY FORM
(Please print)
Name: _________________________________________
Date of Birth: _________________________________
Race:
American Indian or Alaskan Native
Asian
African-American
More Than One Race
Native Hawaiian
Other Pacific Islander
Caucasian
Refused to Report/Unreported
Ethnicity:
Hispanic or Latino
Non-Hispanic or Latino
Refused to Report/Unreported
Language:
English
Spanish
Other: _______________________________________________________
Pharmacy: ________________________________________________________________________________________
(Name/City/Phone #)
Do you use a mail order pharmacy? ____________ If so, please be sure we have your pharmacy provider information
and a copy of your prescription drug card.
Mail Order Pharmacy: ______________________________________________________________________________
REASON FOR COMING TO THE DOCTOR TODAY:
Reason for Today’s Visit: ____________________________________________________________________________
Timing/Onset:
When did symptoms first occur? ______________________________________________________________________
Is this due to an accident? ___________________________________________________________________________
Duration:
Frequency of symptoms? ____________________________________________________________________________
Characterized as/Severity:
Describe the severity of the symptoms/pain. _____________________________________________________________
Associated Signs and Symptoms:
Are there any other symptoms associated with your problem? _______________________________________________
Modifying Factors:
What makes the condition better and/or worse? __________________________________________________________
Have you been treated for this condition by any other provider? If yes, please name. ___________________________
Diagnostic Imaging:
Have you had previous diagnostic imaging done (i.e. MRI, x-ray, CT Scan, EMG)? If so, when and where: ______________
__________________________________________________________________________________________________
Problem List/Past Medical History:
Have you been diagnosed with any of the following (currently or in the past)?
___ Alcoholism
___ Diabetes
___ Osteoporosis
___ Arthritis
___ Fibromyalgia
___ Parkinson’s Disease
___ Asthma
___ GERD (Reflux Disease)
___ Seizures
___ Bleeding Disorder
___ Gout
___ Sleep Apnea
___ Blood Clot
___ Heart Disease
___ Thyroid Disorder
___ Cancer
___ High Blood Pressure
___ Wound Infection
___ COPD
___ High Cholesterol
___ Depression
___ Kidney Disease
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