New Patient - Schmitt

Integrative Spine & Body Medicine

Dr. Susan Schmitt
NEW PATIENT FORM
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age
Today

MonthDayYear
Date
Referral Doctor

List your primary complaints today (in order of most severe):


1.
2.
3.
4.

When did your pain problem first occur (exact date if known)?
For Auto Injury:

DriverPassenger
Seat Belt:

YesNo
Vehicle Owner:

PersonalWork
Vehicle Type:

CarPickupVanMotorcycleBusBicyclePedestrian
How did it happen (check one)?

Auto accidentAccident at workAccident at homeSurgeryFollowing illnessPain just began-cannot relate it to anythingOther
Where did the injury occur?
What activity were you doing when this happened?
Describe what caused your injury
How did your problem start?

SuddenlyGraduallyOver weeksOver daysOver monthsOther
How is your problem doing now?

BetterSlightly betterNo changeWorseMuch worse
Have you injured this area/areas before?

YesNo
Description of pain (check all that apply)

BurningSharpShootingAchyDullConstantFluctuatingNumbTingling
Please fill out the pain diagram to the right (We will have you fill in the diagram at the time of your visit):

(shade painful body regions to show where the pain is)

(apply “X” for numbness/tingling areas)
Front

RightLeft
Back

RightLeft
Is there weakness:

R armL armR legL legBackNeckOther

Maximum time you can:

	Sit	Stand	Walk	Lift (lbs)
hr/min/lbs

Is there numbness

NoYes
If Yes (where)
Trouble sleeping?

NoA littleA lot
# hours of sleep at night
Positions that worsen your pain
Positions that lessen your pain
Work status (check all that apply):

RetiredLaid offStudentFull timePart timeMedical leaveSelf-employedHomemakerNot working (describe)
If Part time, # of hrs
If Not working (why?)
Job title current
Employer name
Length of employment (years)
(months)
List dates of missed work:
Currently on work restrictions

YesNo
If Yes (list dates)
List previous 2 jobs

List all names of health care providers (doctors, chiropractors, physical therapists, massage therapists, counselors, etc you have seen since the accident for this condition:


1.
2.
3.
4.
5.

Diagnostic tests done for your problem:

	Approx Date	Facility
X-ray (body part)
CT (CAT Scan)
MRI
Bone Scan
EMG/Nerve conductions

Medical history (please indicate if you have had any of the following conditions):
Previous Motor Vehicle Accident:

YesNo
If Yes, Year
List injuries
Previous Work Comp Injury:

YesNo
If Yes, Year
List injuries
Back painNeck painMigrainesDiabetesUlcersThyroid conditionFibromyalgiaGlaucomaSeizuresEmphysemaAsthmaSleep apneaStrokeHeart attackHeart murmurCongestive heart failureIrregular heart beatOther heart problemsHigh blood pressureBlood clots/phlebitisCancerGoutPsoriasisRheumatoid arthritisOsteoarthritisProblems with anesthesiaHepatitisOther
Surgical history (indicate all prior surgical procedures and approximate dates)
Hernia repairAppendectomyGall bladder removalStomach scopeEye surgeryLung surgeryHeart catheterizationHeart surgeryBladder surgeryProstate surgeryUterus removedBreast surgeryJoint surgeryHistory of fractureOther
Current medications (list all prescription and non-prescription drugs you are currently taking):
List all medications you are allergic to
Problems with:
Steriods

NoYes
NSAIDS

NoYes
Latex

NoYes
Family history of:

OsteoarthritisRheumatoid arthritisPsoriasisGoutDiabetesLung problemsThyroid problemsHeart problemsHigh blood pressureCancer (type)Other (describe)
Cancer (type)
Other (describe)
Social History: Marital status:

SingleMarriedDivorcedWindowed
Number of children
Do you smoke?

NoYes
If Yes (packs per day)
Previously smoke?

NoYes
If Yes (year quit)
Do you drink alcohol?

NeverOccasionallyModeratelyHeavy
High risk behavior:
Recreational drugs?

NoYes
IV drugs?

NoYes
Close contact with IV drug users?

NoYes
Current Height
Current Weight
Review of systems (check if you have had any of these symptoms over the past few months):
Eye:

Blurred visionDouble visionBlindness in one eye
Ear, nose, throat:

Hard of hearingRinging in earsSinus problemsSore throatTMJ problemsFullness in ears
Stomach, Intestines:

Trouble swallowingNausea/vomitingDiarrheaAcid indigestionRectal bleedingConstipation
Lungs:

Shortness of breathWheezingCoughingBad snoring
Heart:

Chest pain/tightness on exertionChest pain/tightness at restPalpitations/racing heartSwelling in ankles/feetAching in legs when walking
Urinary:

IncontinenceDifficult urinationSlow streamFrequent urinationStinging with urinationProstate problems
Neurologic:

Fainting/black-out spellsUnsteady walkingPoor balanceSeizures/convulsionsNeck painNumbness or tingling in extermitiesBack pain
Blood, lymph:

AnemiaEasy bruisingProlonged bleedingSwolen lymph glands
Bones, joint, muscles:

Joint pain (where)Joint swelling (where)Muscle pain (where)
Joint pain (where)
Joint swelling (where)
Muscle pain (where)
Skin:

RashesItchingChanges in moles
Mental health:

DepressedAnxiousStressedHallucinations
Overall health:

Fever/chills/sweatsWeight lossWeight gainLoss of appetiteFatigue
NOTE: If this visit is due to an auto accident, please fill out page 5. Everyone else, you are finished. Thank you!

Show Auto Accident Form
Auto Accident Only

Please fill in the following info about the vehicles involved:

	Year	Make	Model
Your car
Other car

Were you:

DriverPassenger in frontPassenger in back
Were you wearing a seatbelt?

NoYes
If Yes, please specify:

Lap beltShoulder-lap belt
Did the vehicle strike you from:

BehindDriver's sidePassenger sideFront
Were you aware of the approaching collision prior to impact?

NoYesSurprised
Were you facing forward at time of impact:

NoYes
Did you lose consciousness (black out) upon impact?

NoYes
If Yes, how long
What was your car doing at time of impact (check all that apply)

StoppedMovingTurningSlowing downSpeeding upTraveling at steady speed
Describe the events of the accident to the best of your knowledge:
Did the police come to the accident?

NoYes
Were you taken to the hospital?

NoYes
If Yes (which one)
How did you get to the hospital?

SelfAmbulanceDriven by
If Driven by, describe:
Did any part of your body strike any part of your car (steering wheel, windshield, door, etc, after impact?

NoYes (describe)
If Yes, describe:

When did you first notice any pain or injury from the accident (describe area of body involved)?


Immediately
Several hours later
Later that evening
Next Day

Have you been in previous accidents?

NoYes (describe)
If Yes, describe:
Did you have any pain problems immediately prior to this accident?
Neck pain:

NoYes (describe)
Yes (describe)
Headaches:

NoYes (describe)
Yes (describe)
Other:
Were X-rays taken at the hospital?

NoYes (describe)
If Yes, describe:
When is the next time you sought medical care after the accident?
List your primary complaints today from the accident in order of most severe:
1.
2.
3.
4.
5.
6.

Should be Empty:

Integrative Spine & Body Medicine

NEW PATIENT FORM

Auto Accident Only