Non Prolotherapy Patient Intake Form
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1 Non Prolotherapy Patient Intake Form Scottsdale Pain Rehabilitation & Wellness Fred G. Arnold, N.M.D East McDonald Drive, Suite 100 Scottsdale, AZ (O) Fax: Date Name Age Date of Birth Home Address City State Zip Home Phone Work Phone Cell Phone Spouse s Name Highest level of education Occupation Employer Hours work per week Marital Status (circle): Single Married Separated Divorced with Partner Widow(er) Person to call in case of Emergency Relationship to you Phone number contact for them: Regular Physician Phone # Please indicate how you found out about our office? Newspaper- Which one? Health Magazine- Which one? Local talk or lecture- Which one? Internet- Which category? Doctor referral- Who? Friend or Relative- Who? Health Information List in Order of Importance what your concerns are: Last time you had blood work done and with what doctor:
2 Family history Father Mother Grandparents Age if living Age when died High Blood Pressure Y N Y N Y N Heart disease Y N Y N Y N Asthma/allergies Y N Y N Y N Auto-immune disease Y N Y N Y N Diabetes Mellitus Y N Y N Y N Osteoporosis Y N Y N Y N List All Surgeries and Hospitalizations including date occurred: Please List All Sensitivities/Allergies/Reactions Drugs: Foods: Environment: List Yes, No, or Past regarding use of the following: Antacids: Y N P Steroids: Y N P Smoking: Y N P Packs per day if Yes/Past: Analgesics: Y N P Laxatives: Y N P Coffee: Y N P Cups per day if Yes/Past: Soda Pop: Y N P Ounces per day if Yes/Past: Alcohol: Y N P How often and how much if Yes/Past: Any alcohol addiction: Y N P Any alcohol treatment: Y N P Recreational drugs: Y N P Any drugs addiction: Y N P Any drug treatment: Y N P List all Prescription Medicines and Nutrient Supplement/Herbs Taking: Drug Dosage Frequency/How Often Purpose
3 Supplements: Dosage Frequency/How Often Purpose Review Of Systems: Present Weight: Height: Ideal Weight: Weight one year ago: Overall Energy Level: 0 (the worst) to 10 (the best) circle the level that best describes your energy level now. If you have fatigue, when in morning, afternoon, evening is it the worst?: If you have fatigue, can you do what you need to during the day?: Y N Overall Sleep Level: 0 (the worst) to 10 (the best) circle the level that best describes your quality of sleep now. Overall Digestion Level: 0 (the worst) to 10 (the best) circle the level that best describes your quality of digestion now. Overall Stress Level: 0 (the worst) to 10 (the best) circle the level that best describes your stress level now. REGARDING THE NEXT LONG SECTION: Please Circle Y if you have the problem NOW, N if you ve NEVER had the problem, P if you had the problem in the PAST. Skin: Rash: Y N P Color Change: Y N P Hives: Y N P Lump: Y N P Psoriasis/eczema: Y N P Itchy: Y N P Dry: Y N P Perspiration: Y N P Cancer: Y N P
4 Head: Headache: Y N P Migraine: Y N P Dandruff: Y N P Head Injury: Y N P Oil/dry hair: Y N P Hair loss: Y N P Eyes: Dry/Watery: Y N P Blurry vision: Y N P Double vision: Y N P Cataracts: Y N P Glaucoma: Y N P Dark under eyelid: Y N P Strain: Y N P Discharge: Y N P Itchy: Y N P Nose: Frequent colds: Y N P Nosebleeds: Y N P Congestion: Y N P Post nasal drip: Y N P Polyps: Y N P Seasonal allergies: Y N P Mouth/Throat: Canker sores: Y N P Cold sores: Y N P Sore throat: Y N P Gum disease: Y N P Dentures: Y N P Hoarseness: Y N P Loss of taste: Y N P Neck: Stiffness: Y N P Swollen glands: Y N P Full movement: Y N P Tension: Y N P Respiratory: Cough: Y N P Wheezing: Y N P Shortness of breath with exertion: Y N P Bronchitis: Y N P Pneumonia: Y N P Painful breathing: Y N P Asthma: Y N P Cardiovascular: High blood pressure: Y N P Low blood pressure: Y N P Murmurs: Y N P Arrhythmias: Y N P Palpitations: Y N P Swelling: Y N P Chest pain: Y N P Gastrointestinal: Heartburn: Y N P Bowel movement frequency: Indigestion: Y N P Recent change in BM: Y N P Bloating: Y N P Diarrhea or constipation: Y N P Nausea : Y N P Hemorrhoids: Y N P Vomiting: Y N P Gall bladder disease: Y N P
5 Change in Appetite: Y N P Liver disease: Y N P Pancreatitis: Y N P Ulcer: Y N P Urinary Tract: Incontinence: Y N P Pain with urination: Y N P Frequent infections: Y N P Kidney stones: Y N P Urgency: Y N P Discharge/blood: Y N P Male Genitalia: (Male Only) Testicular pain/swelling: Y N P Sexually active: Y N P Hernia: Y N P Sexually transmitted disease:y N P Discharge: Y N P Prostate disease/symptoms: Y N P Impotency: Y N P Female Genitalia: (Female Only) Age periods began: How often periods occur: How long periods last: Menopausal since what age: Date of last period: Periods: Times Pregnant: Heavy Bleeding: Y N P How many births: Cramping: Y N P Miscarriages: Pain: Y N P Abortions: PMS: Y N P Sexual Active: Y N P Food Cravings: Y N P Healthy Libido: Y N P Last Pap Smear: Pain With Intercourse: Y N P Diagnosis: Dry Vagina: Y N P Any abnormal paps: Y N P Vaginitis: Y N P When was abnormal: Y N P Any Birth Control (please list types and ages used): Mammography: Y N P Dexa Scan: Y N P If Yes, what were the results: Use of Hormones: Y N P Musculoskeletal: Weakness: Y N P Arthritis: Y N P Stiffness: Y N P Leg cramps: Y N P Tremors: Y N P Pain: Y N P Nervous: Paralysis: Y N P Sciatica: Y N P Tingling/numbness: Y N P Carpal tunnel syndrome: Y N P Seizures: Y N P Fainting: Y N P
6 Mental/Emotional: Depression: Y N P Anger/irritability: Y N P Suicidal: Y N P High Stress: Y N P Anxiety: Y N P Fear/Panic: Y N P Exercise: How often: What type(s): For How long: Sleep: How long per night: If you wake up frequently, what is the reason: Nightmares: Y N P Wake refreshed: Y N P Must Nap during the day: Y N P Sleep walk: Y N P Grind Teeth: Y N P Snore: Y N P Food: Appetite Good? Y N P Foods crave: Foods Dislike: Foods that don t sit well: I will be paying by CASH CHECK CREDIT CARD I understand and agree that, regardless of my insurance status, I am responsible for all charges at this office at the time professional services are rendered. I agree to the services and fees rendered in this office and that they will not be subject to dispute by my insurance company. I certify that the information on this patient information form is true and correct to the best of my ability. I agree to notify you of any changes in my health status, address, etc. I understand that there is an OFFICE VISIT CHARGE for evaluation or reevaluation for all visits, in addition to any TREATMENT CHARGE. I understand that this office is NOT A MEDICARE PROVIDER and Medicare will NOT reimburse me for my medical expenses here and I will NOT submit any claims from this office to Medicare. I understand that the Doctor or his staff will not submit claims to Medicare and that the doctor will not receive any direct or indirect payments from Medicare or Medicare related plans.
7 I understand that this office is not a provider for other health care plans or insurance and that this office will not submit claims to them. I understand that the Doctor does not provide emergency or urgent care services as defined in the Social Security Act. I understand that all services normally covered by Medicare, such as X-Rays, Lab work and physical therapy, will not be covered under this Doctor s prescription. Release of Information: Unless I indicate otherwise, I give Dr. Fred Arnold and Staff of Scottsdale Pain Rehabilitation and Wellness permission to discuss and/or release my personal health information to family members, other physicians, testing facilities, and diagnostic centers on an individual basis. If there is any specific person or organization, I do not wish my personal health information to be released to, I will indicate that on this form: Do not discuss or release my personal health information to the following: Anyone or any organization. The following specific individual(s) or organization(s): Patient s Signature Date
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Patient Intake Form DATE: Patient Name: List in Order of importance what your problems are: 1) 2) 3) DOB: Last time you had wellness checkup and with what physician: Family History Father Mother Siblings
Date of Birth Gender. List, in order of importance, your goals for working with your physician:
List, in order of importance, your goals for working with your physician: 1. 2. 3. 4. 5. Please list your allergies and what happens when you are exposed to the allergen: Drug Allergies: Food Allergies:
Family History. Patient Name: DOB: List in Order of importance what your health concerns are: 1) 2) 3) 4) 5)
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