Mail Id: abhi_34358@rediffmail.com

Appointment: +03326784358 /+91 8420418499

Patient Form

Patient Name:

First Name

Middle

Last

Age

Height

Weight

Date of Birth

Gender

  Female    Male

I am:     Left Hand Dominant       Right Hand Dominant

Primary Care Physician

Who recommended you to see us:

Name

Primary Dr.?     Yes     No

If other kindly explain

Chief Complaint: Why are you here?

Date of injury or onset of symptoms

Body part to be examined

 Left     Right

(Check all that apply)

Main Problem

 Pain
 Unstable

 Numbness
 Swelling

 Weakness
 Popping/Grinding

 Stiffness
 Other

Where complaint/injury occurred

 Work
 Car accident

 At home
 At school

 Sports/Recreational
 Other

How complaint/injury occurred

 Gradual
 Unknown

 Onset
 Other

 Sudden/Traumatic

Severity of pain

 Mild

 Moderate

 Severe

 Extremely severe

Quality of Pain

 Sharp

 Dull

 Stabbing

 Throbbing

 Aching

 Burning

Previous and/or current treatments for this condition (Check all that apply)     None

X-rays/Tests:

 Regular x-rays

 MRI scam

 CAT scan

 Myelogram

 Nerve tests (EMG NCV)

 Other

Did you bring your X-rays with you?

Medications:

 Anti-inflammatory

 Muscle relaxants

 Pain medication

 Other

Therapies:

 Physical therapy

 Chropraetie care

 Pain medication

 Other

Are you Pregnant?

 Yes

 No

General Medical History

Are you affected by any of the following? (Check all that apply)     No medical problems

 Abnormal heart rhythm

 Bleeding disorders

 Depression

 Heart attack

 High blood pressure

 Lung Problems

 Sleep apnea

 Acid reflux

 Blood clots

 Diabetes

 Heart failure

 HIV

 Osteoporosis

 Stomach ulcers

 Asthma

 Cancer

 Gout

 Hepatitis

 Kidney problems

 Rheumatoid arthritis

 Stroke

If you checked any of the above please explain

Social History (Check all that apply)

A. Occupation

B. Are you on

 Full Duty

 Light Duty (since:)

 Disabled (since)

C. Do you use tobacco products?

 No

 less than 1 pack

 1 pack

 more than 1 pack

D. Smoking status:

 Current every day smoker
 Never smoker

 Current some day smoker
 Former smoker

 Smoker current status unknown 
 Unknown if ever smoker

E. Do you use alcohol?

 No

 Occasionally

 Daily

F. What is your living status?

 Alone

 With spouse

 With parents

 With room mate

 Assisted living/nursing home

Patient Information

Have you been a patient here before?

 Yes      No

Which doctor are you here to see?

Patient Name

First

Middle

Last

Mailing Address

Street

Apt

City

State

Zip

Home phone

Cell/Alternate phone

Age

Date of Birth

Social Security

Gender

 F     M

Email

Would you like our FREE Doctor's Orders-e-newsletter

 Y      N

Marital status

 Married      Single

 Divorced

 Widowed

Spouse's Name

Emergency Contact Name

Relationship to patient

Home phone

Cell /Alternate phone

Referred By

Name

Primary Dr?

 YES      NO

Other please explain

Legal/Disability/Liability Claims: (Please complete if your visit is the result of legal disability or liability issue

Date of injury/accident

Law office Disability office Name

Lawyer Agent's Name

Phone

Address

City

State

Zip Code

I agree that Bone & joint Clinic, Howrah may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payers for treatment purposes.

I hereby authorize the Bone and Join Clinic to release any medical information and/or medical records maintained at this clinic as needed to my insurance company to the social security administration or aeries to my attorney as listed above or to the attorney responsible for the payment for medical services or evaluation to be provided. I permit a copy of this authorization to be used in place of the original I hereby assign to the facility listed above all Insurance Company or Medicare reimbursements for medical and or surgical expenses in relations pertaining to Medicare assignment of benefits apply I have been given a copy of the notice of Private Practices of Bone and Joint Clinic Howrah Inc

Date

Patient or Responsible Party

Name of person completing form

Relationship to patient

Envious Surgeries

 None

Please list the type and the surgery was performed

1.

4.

2.

5.

3.

6.

Have you ever had a problem with a general anesthetic? (Check one)

 yes, Explain Below      No

If yes, describe any problems

Current medication

 None

Pharmacy Preference and Phone #

Please list any prescriptions drugs and/or non-prescription, including vitamins. nutritional supplements or anything taken orally.

1.

4.

2.

5.

3.

6.

Allergies: Do you have any known drug allergies? (Check one)

 Yes, explain below      No

1.

4.

2.

5.

3.

6.

Family History: Please indicate if anyone in your family has had the following (Check all that apply)

 Cancer (Type)

 Rheumatoid Arthritis

Diabetes

 Scoliosis

 Heart disease

 Other 

 None apply

Review of symptoms:

Are you experiencing any of the following? (Check all that apply)

 Blackouts/Fainting

 Difficulty with balance

 Joint Pain

 Stomach pain or ulcers

 Burning with urination

 Fevers, chills, sweats

 Nausea or vomiting

 Stress

 Back pain

 Frequent rashes

 Neck or shoulder Pain

 Unexplained weight loss

 Cough

 Heart or chest pain

 Seizures

 Urinary incontinence, frequency urgency

 Depression

 Heartburn

 Shortness of breath

 None apply

Patient, Parent, Guardian name

Date

Physician's name

Date

Reviewed by MD

Date

IMI

Date

INIT

Date

INII

Date

Name of person completing this form


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