Home
Why Choose Us?
Start Feeling Better
Contact
New Patient Questionnaire
History and Physical Questionaire
Nursing Assessment / Patient Reported History
First Name
*
Initials
Last Name
*
Reason for the visit
*
Addiction
Pain Management
Ketamine Infusion
Anxiety Disorder
Diagnosis
Opioid Dependence
Alcohol dependence
Methamphetamine dependence
Severe depression
Anxiety disorder
Chronic Pain
Medications
Medication
Add
Remove
Medication Allergies & Symptoms
Medication Allergies
Cadiovascular
None Reported
Myocard infarct:
Myocard infarct:
Date
Hypertension
Hypertension
Arrhythmia
Arrhythmia
type
Chest Pain
Chest Pain
Pacemaker
Pacemaker
AICD
AICD
CHF: Date
EF (%)
Acute
Acute
Chronic
Chronic
Valve disease
Moderate
Moderate
Severe
Severe
Past Cardiac Surgery
Past Cardiac Surgery
PVD
PVD
Angioplasty
Angioplasty
Deep vein thrombus
Deep vein thrombus
Pulmonary Embolus
Pulmonary Embolus
Heart Murmur
Heart Murmur
Stress test / cardiac cath
Stress test / cardiac cath
Hyperlipidemia
Hyperlipidemia
Cardiomyopathy
Cardiomyopathy
Pulmonary
None Reported
Shortness of Breath
Shortness of Breath
Smoking history in last 12 months
Smoking history in last 12 months
Asthma
Asthma
Steroid use
Steroid use
Hospitalized
Hospitalized
Recent wheezing
Recent wheezing
Cough: active / chronic
Cough: active / chronic
Sinus congestion
Sinus congestion
Renal
None Reported
Renal failure
Renal failure
Nephrolithiasis
Nephrolithiasis
Dialysis
Dialysis
Other
Other
Hepatic
None Reported
Hepatitis
Hepatitis
Cirrhosis
Cirrhosis
Other
Other
Endocrine
None Reported
Diabetes
Diabetes
AM FSBS =
AM FSBS =
AM FSBS Details
Steroid use
Steroid use
Thyroid
Thyroid
Hypothyroid
Hypo
Hyperthyroid
Hyper
Neurologic
None Reported
Seizure
Seizure
Chronic pain
Chronic pain
Migraine
Migraine
Blind
Blind
Blind: right / left
right
left
Spinal cord injury
Spinal cord injury
Level:
Back Pain
Back Pain
Neuropathy / paresthesia
Neuropathy / paresthesia
Extremity weakness
Extremity weakness
Extremity weakness - details
Cerebral palsy
Cerebral palsy
Myopathy / muscular dystrophy
Myopathy / muscular dystrophy
CVA / TIA
CVA / TIA
Residual symptoms:
Elevated ICP
Elevated ICP
Shunt
Shunt
Syncope
Syncope
Dementia
Dementia
Gastrointestinal
None Reported
GE Reflux
GE Reflux
Ulcers
Ulcers
Hiatal Hemia
Hiatal Hemia
Heartburn
Heartburn
No SX
No SX
Other
Other
Other - details
Hematol / Onc
None Reported
Sickle cell disease
Sickle cell disease
Trait
Trait
Coagulopathy
Coagulopathy
Anemia
Anemia
Past Transfusion
Past Transfusion
Refuses Transfusion
Refuses Transfusion
Obstetrics
None Reported
Preeclampsia / eclampsia
Preeclampsia / eclampsia
Placenta previa / abruption
Placenta previa / abruption
Miscarriage
Miscarriage
Infant Death
Infant Death
Drug Use
None Reported
Alcohol
Alcohol
Benzodiazepines
Benzodiazepines
Drug Use with Needle
Drug Use with Needle
Cocaine
Cocaine
Methamphetamine
Methamphetamine
Marijuana
Marijuana
Opioids
Opioids
Heroin
Heroin
Ecstacy
Ecstacy
Activity Level
None Reported
Bedridden
Bedridden
Assistance with self-care
Assistance with self-care
Baseline Status <1 flight of stairs
Baseline Status <1 flight of stairs
1-2 flights of stairs
1-2 flights of stairs
>3 flights of stairs
>3 flights of stairs
Exercises
Exercises
Able to lie flat one hour
Able to lie flat one hour
Prescreen Vital Signs
HT (inches)
*
WT (pounds)
*
Review Of Systems
General
None Reported
Fatigue
Now
Past
Fever
Now
Past
Weakness
Now
Past
Weight Loss
Now
Past
Eyes
None Reported
Blurry
Now
Past
Double
Now
Past
Pain
Now
Past
Floaters
Now
Past
Ears
None Reported
Hearing Loss
Now
Past
Earache
Now
Past
Discharge
Now
Past
Ringing
Now
Past
Nose
None Reported
Bleeding
Now
Past
Loss of Smell
Now
Past
Obstruction
Now
Past
Sinus problem
Now
Past
Throat
None Reported
Soreness
Now
Past
Swallowing
Now
Past
Infections
Now
Past
Head
None Reported
Headaches
Now
Past
Injuries
Now
Past
Dizziness
Now
Past
Skin
None Reported
Rashes
Now
Past
Itching
Now
Past
Dryness
Now
Past
Mole Changes
Now
Past
Sores
Now
Past
Mouth
None Reported
Bad breath
Now
Past
Bleeding Gums
Now
Past
Ulcers
Now
Past
Dental Problem
Now
Past
Loss of Taste
Now
Past
Chest
None Reported
Short Breath
Now
Past
Cough
Now
Past
Chest Pain
Now
Past
Wheezing
Now
Past
Breasts
None Reported
Lumps
Now
Past
Pain
Now
Past
Discharge
Now
Past
Heart
None Reported
Cold Extremity
Now
Past
Ankle Edema
Now
Past
Murmur
Now
Past
Varicosity
Now
Past
Blood Clots
Now
Past
Palpitations
Now
Past
Gastroint
None Reported
Abdominal Pain
Now
Past
Nausea
Now
Past
Vomiting
Now
Past
Diarrhea
Now
Past
Constipation
Now
Past
Bloody Stool
Now
Past
Black Stool
Now
Past
Jaundice
Now
Past
Heartburn
Now
Past
Hemorrhoids
Now
Past
Belching
Now
Past
Loss of Appetite
Now
Past
Genitourin
None Reported
Urine Hesitancy
Now
Past
Incontinance
Now
Past
Urgency
Now
Past
Frequency
Now
Past
Kidney Stones
Now
Past
Woman
None Reported
Painful Sex
Now
Past
Discharge
Now
Past
Irreg Periods
Now
Past
Hot Flashes
Now
Past
Loss of Libido
Now
Past
Spotting
Now
Past
Heavy Flow
Now
Past
UTI
Now
Past
Man
None Reported
Impotence
Now
Past
Loss of Libido
Now
Past
Dribbling
Now
Past
Blood/LYMPH
None Reported
Bruising
Now
Past
Bleeding
Now
Past
Anemia
Now
Past
Swollen Glands
Now
Past
Endocrine
None Reported
Heat Intolerant
Now
Past
Cold Intolerant
Now
Past
Weight Loss
Now
Past
Weight Gain
Now
Past
Hair Changes
Now
Past
Musculosk
None Reported
Joint Stiffness
Now
Past
Joint Pain
Now
Past
Muscle Pain
Now
Past
Muscle Cramps
Now
Past
Muscle Spasms
Now
Past
Psychologic
None Reported
Anxiety
Now
Past
Depression
Now
Past
Loss of Interest
Now
Past
Phobias
Now
Past
Suicidal Ideas
Now
Past
Drugs
Now
Past
Alcoholism
Now
Past
Hallucinations
Now
Past
Insomnia
Now
Past
Neurologic
None Reported
Numbness
Now
Past
Tingling
Now
Past
Seizures
Now
Past
Incoordination
Now
Past
Memory Loss
Now
Past
Vertigo
Now
Past
Difficult Speech
Now
Past
Paralysis
Now
Past
Hand Tremors
Now
Past
reCAPTCHA
Submit
