RETURNING PATIENT FORM
Please take the time to answer all questions that apply to your return visit.
Date:
/
Month
/
Day
Year
Date
Name:
*
Email
*
example@example.com
Date of Birth:
-
Month
-
Day
Year
Date
AGE:
Changes to Address:
*
Yes
No
If yes, new address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Changes to Phone:
*
Yes
No
New Phone Number
-
Area Code
Phone Number
Changes to Insurance:
*
Yes
No
Upload Copy of New Insurance Card
Browse Files
Front and Back
Cancel
of
Reason for appointment:
Scoliosis Follow-‐Up
Routine Post-‐Op
Routine Follow-‐up
New Problem
Since your last appointment, have you had:
P.T.
Injections
Medications
None
Please list any new medical problems since your last appointment:
Please list any surgeries since your last appointment:
List all of your medications and vitamins/supplements:
Allergies: (Drugs, Foods, Environmental)
NO KNOWN ALLERGIES
Latex
Penicillin
Keflex
Sulfa Type Drug
Other types of Antibiotics
Anti-‐Inflammatories
Aspirin
Codeine
Morphine
Hydrocodone
Other Medication
Anesthetics/History of Malignant Hyperthermia including family members
Other
Smoking:
Yes
No
If yes, how long?
In Years
How many packs per day?
Have you quit smoking:
Yes
No
When did you quit?
How long did you smoke before quitting?
In Years
Do you chew or dip tobacco?:
Yes
No
If Yes, How much?
Alcohol:
Yes
No
If yes, what type and how much per day?
Back
Next
If you are having any pain, please complete the following.
If not, please skip and submit below.
Date:
/
Month
/
Day
Year
Date
Patient Name:
Neck Pain: Click Severity Level
1 (Minor)
2
3
4
5 (Moderate)
6
7
8
9
10 (Severe)
Pain in arm(s) compared to neck:
Worse than
Same as
Less than
Upper Back Pain: Click Severity Level
1 (Minor)
2
3
4
5 (Moderate)
6
7
8
9
10 (Severe)
Low Back Pain: Click Severity Level
1 (Minor)
2
3
4
5 (Moderate)
6
7
8
9
10 (Severe)
Pain in leg(s) compared to back::
Worse than
Same as
Less than
Are you getting:
Better
Worse
Unchanged
Does the pain come on:
Suddenly
Gradually
Are you usually in:
Mild discomfort
Moderate discomfort
Severe discomfort
Pain is:
Constant
Good & Bad Days
Pain is worse in the:
Morning (6am–12pm)
Afternoon (1pm‐8pm)
Night (8pm–6am)
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Submit
Should be Empty: