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••••••••ilt 44444444 lif• sante Mrs ••••••• Medicine Intake Form: New Patient Name: JEFFge‘l e*PS‘Te/r4 Date of Birth: Age: (..,"t Phone: .2 1 a - Sp- 9 V9S- CC: What problem/issue brings you here today? mistmisitimmi Today's Datej5/ i t 1,40 Primary MD: ble. sk-tosr-oLon-z- Referred By: Da itiCsKADLOLTZ- How and when did it start? What makes it worse? walking sitting standing I lying down (exercise nothing }Other: What makes it better? walking sitting standing I lying down exercise nothing Other. What do you want to accomplish from today's visit? Diagnosis I Treatment Options X-ray MR1 i Meds Review Test Injection Is this a Worker's Compensation Claim or is there litigation pending? Yes No What diagnostic tests have you had for this problem? None I X-ray MRI CT EMG ics consult What treatments have you had? None i Mel I Physical therapy 1 Chiropractor Psychotherapy Injections Surgery Please make a mark on the line below to indicate the level of discomfort you have today. No Pain Worst Pain Ever 0 I 2 3 a 5 6 7 8 9 la Please describe what the pain feels like: Achy, Burning, Cramping, Stabbing, Stiff, Tingling, Numbness, Dull, Tight, Pulling Please describe the time course of your pain: Constant, Comes and goes, Getting worse, Getting better, Staying about the same Medical History: Diabetes, Cancer, Please shade all locations you High Blood Pressure, Pacemaker, have pain or discomfort Arthritis, Osteoporosis, Other. Surgical History: N JAL. Medications: (Use rt page V needed) Allergies to medicines: Family Histmy: (please include only Family member: Condition: I° degree relatives (parents, siblings. children)) (ag. strie't rheumatoid cribs-hit) Social History: What do you do for exercise? Tobacco use (cigarette, cigar, pipe, chew): Current Quit Number of alcoholic beverages per week? OcettWon: Physical requirementsTN:goosed Sitting Employment status: 1 Full-time Part-time I Light Duty Prolonged Standing Lifting) Travel iDrivingCompu ter Off Duty due to injury Phone Childcare Full-time Parent , Not working Retired Fenn, unintentional weight change? Yes 0 Vision change, double vision? Yes 1 10 Difficulty swallowing, headaches? Yes No Chest pain, palpitations? Yes tl, Shortness of breath, wheezing, cough after exercise? Yes 'es. Nausea, vomiting, black stools, loss of control of stools? Yes 1 Loss of control of urine, urinary frequency or urgency? Yes o t, New rashes or psoriasis or skin lesions? Yes No Dizziness, weakness, numbness, tingling? e No Depressed mood, sleep problems, anxiety? Yes No Current low back pain, other joint swelling or muscle pain? Yes No 2 Are you pregnant, trying to get pregnant or breastfeeding? Yes No Patient's Signature: 2 Last menstrual period date: Periods regular? Yes No Physician Initials/Date: / / EFTA00313689