pmr new patient paperwork

Premier Medical Rehab - LaPlace
NEW PATIENT INFORMATION
The following is needed so we can better serve you as a patient. PLEASE PRINT
Date____________________
Patient’s full name_____________________________________________________________________
Birthdate_________________
Mailing address
Age_____________
Social Security Number___________________
________________________________________
City, State, Zip
________________________________________
Home Phone
__________________
Cell Phone ___________________
Email Address
_______________________________________________________
Employer _____________________________Occupation_________________ Work Phone________________
Sex:
Male
Female
Marital Status: (circle one)
Married
Single
Legally Separated
Divorced
Widowed
Other ________________
Number of children __________________
Are You Pregnant? Yes
No Date of your last menstrual period ________________
Emergency Contact Person/ Relationship ____________________________________Phone________________
History Information
Was your injury related to: Employment / Automobile Accident / Other
Date of Injury _________________________
Did you see any other doctors or were you taken to the hospital for this accident? Describe. ___________
_____________________________________________________________________________________
Have you had any surgeries in your lifetime?
Yes
No
If yes, describe. ________________________________________________________________________
Briefly describe the pain that you are having as a result of your injury.
_____________________________________________________________________________________
_____________________________________________________________________________________
Briefly describe your accident_____________________________________________________________
_____________________________________________________________________________________
Which Pharmacy do you use? _____________________________________ City/ State _____________________
Patient Name_____________________________________________
Date of Accident __________________________________________
Attorney Information
Name
______________________
Address
______________________
City, State, Zip
______________________
Phone Number
______________________
Insurance Information
Company ___________________________
Claim # _____________________________
Adjuster _____________________________
Adjuster Contact ______________________
Adjuster Fax__________________________
Address _____________________________
____________________________________
Patient Name _____________________________________ Room___________
Date of Birth ______________________ Pharmacy? ______________________
Check ALL that describe your pain:
(Marque todo lo que describe su dolor)
O Constant
(Constante)
O Occasional
(Ocasional)
O Burning
(Ardiente)
(Fecha de nacimiento)
Where is your pain today? (Dónde está dolor de hoy?)
(Blando)
O Stabbing
O Numbness
(Punsante)
(entumecimiento)
O Dull/ Aching O Pressure
(Inexplicable)
(Tensión)
O Sharp
O Tingling
(Agudo)
(Hormigueo)
O Shooting
O Nagging
(Punzante)
(persistente)
O Throbbing
O Cramping
(Palpitante)
(Calambres)
(farmacia)
O Tender
O Electric
(Electrico)
Is your pain Better / Worse / Unchanged ?
(Es tu dolor Mejor/Peor/Igual)
What is your usual level of pain?
Have You Had an Injection since your las visit? Yes No
(Has tenido alguna injección desde tu ultima visita?)
(Usualmente cual es tu nivel de dolor)
Percentage of relief from Injection ____________%
¿Cual es el porcentaje de alivio de la injección?
Are medications helping with your pain?
¿ Los medicamentos te están ayudando con el dolor?
Well (bien) Fairly (bastante) Not Very Well (no mucho) Poorly (poco)
Percentage of relief taking pain medications_________%
Pain is WORSE with:
Pain is BETTER with:
(Porcentaje de Alivio tamando medicamentos)
(Tu dolor es peor con:)
O Activity (actividad)
(Tu dolor es mejor con:)
O Resting (descansando)
Current functional level with medication:
O Walking (caminando)
O Lying Down (acostado)
O Standing (de pie)
O Turning on other side
O Sitting (sentado)
O Bending (doblando)
O Lying Flat (acostandose)
(girando el cuerpo)
O Lying on recliner
(nivel functional actual sin medicación)
O Better O Much Improved O Very Poor O Worse O Unchanged
(mejor)
(Mucho mejor)
(Bien poco)
Fair
(Peor)
(ningun cambio)
Quality of sleep :
Good
Poor
(La calidad del sueño)
(Bien) (razonable) (pobre)
(sentadonse en un reclinable)
O Driving (manejando)
O Ice/ Heat (frio/caliente)
Any side effects of prescribed medication?
O Coughing (tosiendo)
O Massage (masage)
(Alguna reacción de los medicamentos recetados)
O Turning Side to Side
O Injections (inyecciónes)
_______________________________________________
O Lifting (levantando)
O Medications (medicamentos) Describe your mood: Good Fair Poor Depressed
O Weather Changes (cambio de tiempo)
O Going Up Stairs
(subiendo escaleras)
(Describe tu estado de ánimo) (Bien) (Razonable) (Deprimido)
O Nothing
(nada)
CONTINUE TO BACK 
Please Circle:
General:
Eyes:
HEENT:
Psychological: (Psicologico)
Fatigue (fatigado)
Changes in Vision
Headaches (Dolor de cabeza)
Depression (Depresión)
Weight Loss
(Cambios en la vision)
Loss of Hearing (Pérdida de audición)
Anxiety (Ansiedad)
Sinus Problems
Difficulty Thinking
(Problemas de sinusitis)
(Dificultad de pensar)
(Ojos)
(Pérdida de peso)
Respiratory
Cardiovascular:
Gastrointestinal:
Shortness of Breath
High Blood Pressure (Alta Presión) Abdominal Pain (Dolor Abdominal) Incontinence (Incontinencia)
Asthma (Asma)
Chest Pain (Dolor de pecho)
COPD/ Emphysema
Poor Circulation (Pobre circulación)Nausea/ Vomiting (Nauseas/Vomitos)Inability to Control Urine
Sleep Apnea
Irregular Heart Beat
Heartburn (Acidez)
(Dificultad de dormir)
(Latidos irregulares del corazón)
Constipation (Estreñimiento)
Reflux (Reflujo)
Urological:
Kidney Stones (problemas renales)
(Incapacidad de controlar la orina)
Stomach Ulcer (Ulcera estomacal)
Musculoskeletal:
Neurological:
Endocrine:
Hematologic:
Muscle Cramps(calambres)Trouble Concentrating
Thyroid Problem (Problemas toroides)Bleeding Disorder (Sangrado)
Neck Pain (Dolor de cuello) Gait Disturbance(Manchas)
Diabetes
Anemia
Shoulder Pain (Dolor del hombre) Stroke (Ataque fulminante) Hepatitis
Easy Bruising (Hematomas fácilmente)
Back Pain(Dolor de espalda) Weakness (Debilidad)
Blood Transfusion
Joint Pain (Dolor en las articulaciones) Seizures (Ataques epilépticos)
(Transfución de sangre)
Joint (Articilación)
Swelling (Hinchazón)
Morning Stiffness (Rigidez matutina)
ANY NEW ISSUES? (Algún problema nuevo)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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OFFICE USE ONLY: (Uso de oficina solamente)
VITALS:
HEIGHT_____________ TEMP______________ BP_____________ RESP.____________