••••••••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 0Vision 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? eNo 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