NEW PATIENT ONBOARDING PACKET
PATIENT INSTRUCTIONS:
We ask patients to arrive 15 minutes early for their initial appointment to prepare for your visit. Please take the time to complete this form as well as the other forms on this site.
PARKING:
There is plenty of parking in front of the building. If you need directions consider the map on the website or you can call us at 978 369 2266.
OFFICE HOURS:
Monday: 9:00am to 4:00pm
Urgent care: 4:00pm- 5:00pm
Tuesday: 9:00am to 8:00pm
Urgent care: 12:00pm- 1:00pm
Wednesday: 9:00am to 4:00pm
Urgent care: 4:00pm-5:00pm
Thursday: 9:00am to 8:00pm
Urgent care: 12:00pm-1:00pm
Friday: 7:30am- 11:45am
Urgent care: 12:00pm- 1:00pm
Saturday: 8:00am- 11:45am
Urgent care: 12:00pm- 1:00pm
Sunday: CLOSED
URGENT CARE:
We have an hour set aside each day for urgent care requests. If you email us before 8:30am on the day you are seeking urgent care, we should be able to see you. There is a $15.00 surcharge for appointments on the same day.
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You can request urgent care on the website or by contacting the staff at
drjeffstaff@drrobichaud.com.
PATIENT HISTORY AND ASSESSMENT:
Name
First Name
Last Name
PATIENT DATE OF BIRTH:
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PATIENT PREFERRED PHONE CONTACT NUMBER:
Format: (000) 000-0000.
PATIENT EMAIL ADDRESS:
example@example.com
PRIMARY CARE PHYSICIAN:
REFERRING CLINICIAN (IF DIFFERENT):
HISTORY OF PAIN AND SYMPTOMS:
What are your main issues that you are seeking treatment for?
When did your symptoms start?
Where are your current symptoms (percentage)?
Spine:
Leg:
Arm:
Head:
Other (specify):
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What event/s led to the onset of your symptoms
What event/s led to the onset of your symptoms
Auto accident
Work related injury
Non work related injury
Trivial incident
No obvious cause
Since the time of the onset of your pain is it...
Since the time of the onset of your pain is it...
Getting worse
Getting slowly better
Not changing much
Are you having difficulty (yes/ no)
Walking distances
y
n
Sitting for long periods
y
n
Standing for long periods
y
n
Performing normal activities
y
n
Sleeping
y
n
REGARDING YOUR CURRENT PAIN IS IT...
Mild
Moderate
Severe
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THINGS THAT ALLEVIATE MY PAIN (CHECK ALL THAT APPLY)
Heat (hot packs/shower)
Ice
Massage
Stretching
Modified activities
Rest
Using a brace
Light activity
Over the counter medications/ supplements
Prescription medication
Other: (please describe)
THINGS THAT AGGRAVATE MY PAIN (CHECK ALL THAT APPLY)
Bending
Twisting
Reaching
Carrying
Sitting
Standing
Working at the computer
Certain movements
Driving
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Other: (describe)
HOW DOES YOUR PAIN IMPACT YOUR LIFE (CHOOSE ONE)
HOW DOES YOUR PAIN IMPACT YOUR LIFE (CHOOSE ONE)
Not much
I can do most things, but the pain annoys me
I have trouble with normal activities, but manage
I can't do normal things comfortably, but do them anyway
In find myself limiting my normal activities because of the pain
I really can't do much
PRESENT MEDICAL ISSUES: (CHECK ALL THAT APPLY)
PRESENT MEDICAL ISSUES: (CHECK ALL THAT APPLY)
High Blood pressure
High Cholesterol
High Blood sugar (Type 1 or Type 2 diabetes)
Cardiac issues (heart)
Pulmonary issues (Lung)
Renal Issues (Kidney)
Cancer
Arthritis (location):
Other: (specify):
CURRENT MEDICATIONS:
1.
2.
3.
4.
5.
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OTHER:
OCCUPATION:
IF WORKING:
Full time:
Part time:
Homemaker:
WOULD YOU SAY YOUR PRESENT LEVEL OF PHYSICAL ACTIVITY AT WORK IS
Sedentary:
Light activity:
Moderate activity:
Heavy labor:
EXERCISE HABITS: (CHOOSE ONE)
I don't exercise on a regular basis:
I am physically busy, but don't exercise formally:
I occasionally exercise:
I have a regular exercise routine:
PLEASE ANSWER THE FOLLOWING YES OR NO
Do you smoke
y
n
Do you drink alcohol
y
n
Have you had a seizure
y
n
Have you ever fainted
y
n
Do you use cannabis
y
n
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Do you feel safe at home
y
n
Have you fallen in the past 3 months
y
n
Do you sleep well
y
n
Are you lonely
y
n
PLEASE SHARE ANY INFORMATION THAT IS IMPORTANT THAT IS NOT COVERED IN THIS FORM:
PATIENT NAME : (PRINTED)
DATE:
-
Month
-
Day
Year
Date
Signature
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