PATIENT INFORMATION



Friedman Spine & Physical Therapy, PC

1340 Morris Ave

Union NJ 07083-3312

(908) 686-4400

Fax: 908-686-4423



reception@

Patient Intake (Personal Injury-Workers Comp)

Please complete this form to the best of your ability:

1. Have you reported the accident?

□Yes (Reported to______________________________)

□No

2. If so, do you have the following information:

a) Claim Number: ___________________________

b) Adjuster’s Name: __________________________

c) Adjuster’s Phone #:_________________________

3. Please provide us with the following information:

a) Drivers License: □Yes □No

b) Police Report: □Yes □No

c) Health Insurance Card: □Yes □No

4. Attorney Information:

a) Attorney’s Name: _________________________

b) Attorney’s Address: _________________________

_________________________

c) Attorney’s Phone #: _________________________

Today’s Date: ____________________

PATIENT INFORMATION

|Last Name: |First Name: |

|Street Address: |City, State, Zip code: |

|Home Phone: |Work Phone: |Cell Phone: |

|Date of Birth: Age: |Social Security Number: |

|At the time of the accident you were:  Working  Unemployed  Temporarily Disabled  Permanently Disabled |

|Employer: |

|Employer’s Address: |

|Job Description: |

|Did you miss any time from work as a result of your injuries sustained in this accident?  Yes  No |

|If you answered “Yes” to missing time from work, how much time did you lose? |

|Marital Status:   Married __# of years   Single   Divorced   Widowed   Separated  |

|Spouse/Partner Name: |

|Number of Children & Ages: |

|Dominant Hand:   Right   Left   Both |

|Height: |Weight: |

|Emergency Contact: | |

|Relationship: | Phone Number: |

|Who can we thank for referring you? | |

|Medical doctor’s name? |Phone Number: |

|Medical doctor’s address? | |

|May we keep your medical doctor updated with regard to your progress? | Yes  No |

ACCIDENT HISTORY AND PRIOR TREATMENT

|Date of the current accident: |Time:  AM  PM |

|Please explain what happened: |

|__________________________________________________________________________________________ |

| |

|__________________________________________________________________________________________ |

| |

|__________________________________________________________________________________________ |

| |

|__________________________________________________________________________________________ |

| |

Did any part of your body strike anything?

| Head | Left shoulder | Left arm | Left hand | Left leg |

| Chest | Right shoulder | Right arm | Right hand | Right leg |

|What did you strike? |

| |

| |

| |

| |

Immediately following the accident, how did you feel?

| unconscious | dazed | anxious | dizzy | disoriented |

| nervous | nauseous | upset | weak | vomited |

| shaken | confused | frightened | distressed | light headed |

| in pain | | | | |

|Other: |

Where did you go immediately following the accident?

| Hospital (EMS) | Hospital (took self) | Home | Work |

|Other: |

|What hospital? |

What type of treatment did you receive at the hospital?

| Clinical evaluation | Injection | Medication |

| X-rays (areas): | CT scan (areas): | MRI (areas): |

| Cervical collar | Lumbar brace/belt | Ice pack |

| Stitches | Given home instructions | Instructed to follow up with MD |

|Other: |

Since the accident, have you seen any other doctors for your injuries?  Yes  No

|What doctor? | |

|Type of treatment? | |

|Treatment beneficial? | |

|Last treatment date? | |

If the symptoms of your present pain have changed since the time of injury, please check the most appropriate statement:

| My symptoms have:  remained the same  are more severe (getting worse)  are less severe (getting better) |

|Have you had previous episodes of neck and/or back pain? |  Yes  No |

|If yes, when was the approximate date of the last episode? | |

|Were you “on the job” at the time of the accident? |  Yes  No |

|Have you had spinal surgery in the past? | Yes  No |

|What type of surgery was performed? | Laminectomy/disc removal | Fusion | Unknown |

|When was the date of your surgery? | |

|Did your condition improve as a result of your spine surgical procedure(s)? | Yes  No |

Please list all other physicians with whom you have consulted in the past for your spine troubles.

|Medical doctor: | |

|Chiropractor: | |

|Neurosurgeon: | |

|Orthopedist: | |

|Pain management: | |

Please mark the areas on the body image below where you feel your current pain and sensations using the appropriate symbols from the list below. Please include all of the affected areas.

|A = Achy |N = Numbness |

|P = Pins & Needles |T = Throbbing |

|B = Burning |D = Dull |

|H = Sharp |G = Tight |

|L = Pounding |R = Radiating |

|S = Stabbing |C = Shooting |

|O = Other | |

[pic]

Pain Frequency:

| Constant | Frequent | Intermittent | Occasional |

Please indicate the effect of these treatments to heal your present injury:

| |Helpful |Not Helpful |Not Used | |Helpful |Not Helpful |Not Used |

|Hot packs: | | | |Tylenol, Advil, Aspirin | | | |

|Ice packs: | | | |Acupuncture: | | | |

|Chiropractor: | | | |Epidural injections: | | | |

|Prescription medication: | | | |Exercise: | | | |

|Physical therapy: | | | |Lumbar belt: | | | |

|Hot showers/baths: | | | |Resting/bed rest: | | | |

|Traction: | | | |Yoga: | | | |

Pain Interferes With:

|□ Work duties |□ Child care |□ Daily routine |□ Recreational activities |□ Sleep patterns |

Which of the following activities change the nature/quality of your pain?

| |Aggravates Pain |Relieves Pain |No Effect | |Aggravates Pain |Relieves Pain |No Effect |

|Sitting | | | |Lying on your side | | | |

|Standing | | | |Lying on your back | | | |

|Rising from sitting | | | |Lying on your stomach | | | |

|Leaning forward | | | |Driving | | | |

|Brushing teeth | | | |Coughing/Sneezing | | | |

|Walking | | | |Sudden movements | | | |

|Lifting | | | |Change in the weather | | | |

|Carrying | | | |Squatting | | | |

|Reaching | | | |Overhead activities | | | |

|Bending over | | | |Recreational activities | | | |

Complaints:

|□ Headache |□ Chest pain |□ Right knee pain |□ Depression |

|□ Dizziness |□ Right shoulder pain/stiffness/painful motion |□ Left knee pain |□ Anxiety |

|□ Blurred vision |□ Left shoulder pain/stiffness/painful motion |□ Right ankle pain |□ Intolerance to hot/cold |

|□ Neck pain |□ Right elbow pain/stiffness/painful motion |□ Left ankle pain |□ Body aches |

|□ Neck stiffness |□ Left elbow pain/stiffness/painful motion |□ Right foot pain |□ Overall stiffness |

|□ Lost/limited cervical motion |□ Right rib pain |□ Left foot pain |□ Fatigue |

|□ Upper back pain |□ Left rib pain |□ Right arm numbness |□ Constipation |

|□ Upper back stiffness |□ Right wrist pain |□ Left arm numbness |□ Mood swings |

|□ Middle back pain |□ Left wrist pain |□ Right hand numbness |□ Reduced sexual function |

|□ Middle back stiffness |□ Right hand pain |□ Left hand numbness |□ Difficulty breathing |

|□ Lower back pain |□ Left hand pain |□ Right leg numbness |□ Hearing loss |

|□ Lower back stiffness |□ Right hip pain |□ Left leg numbness |□ Lack of energy |

|□ Lost/limited lumbar motion |□ Left hip pain |□ Difficulty sleeping |□ Jaw/mouth/chewing pain |

Please check the appropriate box to indicate if you have had/been given any of the following:

| EMG |  Lumbar Belt |

| Bone Scan |  Cervical Pillow |

| Myelogram |  TENS Unit |

| Discogram |  Ice/Hot Pack |

| MRI Area: |  Splint or Brace Area: |

| X-Rays Area: |  Biofreeze/pain gel |

| CT Scan Area: |  Other: |

SOCIAL HISTORY, PERSONAL/FAMILY MEDICAL HISTORY & PRIOR TRAUMA

|Are you pregnant? | Yes  No |

|If so, how many months? |

|Do you have any history of miscarriages? | Yes  No |

|Are you a cigarette smoker? | Yes  No |

|If yes, how much do you smoke per day? |

|Do you drink alcoholic beverages? | Yes  No |

|If yes, how much do you drink per day? |

Are you currently taking any medication?

| Cyclobenzaprine (Flexeril) | Tramadol (Ultram) | Pain patches | Blood pressure medication | Metformin |

| Acetaminophen (Tylenol) | Naproxen (Naprosyn) | Glipizide (Glucotrol) | Birth control pills | Asthma inhaler |

| Oxycodone (Percocet) | Hydrocodone (Vicodin) | Insulin | Cholesterol medication | Thyroid medication |

| Atorvastatin (Lipitor) | Alprazolam (Xanax) | Amitriptyline (Elavil) | | |

How would you rate your current stress level?

| Extreme | High | Moderate/average | Low |

Do you exercise?

| Daily | A few days a week | Infrequently | Never |

Are you allergic to the following?

| Nothing | Shellfish/Seafood | Sulfa drugs | Seasonal | Food | Medication |

|What foods/medications? | |

Surgical History:

|Procedure: |Year: |Procedure: |Year: |Procedure: |Year: |Procedure: |Year: |

|Appendectomy | |Mastectomy | |Shoulder R L | |Prostate | |

|Tonsillectomy | |Hysterectomy | |Caesarean Section | |Foot R L | |

|Neck surgery | |Thyroidectomy | |Gall bladder removed | |Tumor | |

|Back surgery | |Stent/pacemaker/bypass | |Knee R L | |Angioplasty | |

|Hernia | |Breast implants | |Nose job | |Liposuction | |

|Hip replacement R L | |Knee replacement R L | | | | | |

Please mark the appropriate box to indicate if you have had any of the following:

| AIDS/HIV | Depression | Kidney Disease | Psychiatric Care |

| Alcoholism | Diabetes | Liver Disease | Rheumatoid Arthritis |

| Allergy Shots | Emphysema | Lung Disease | Rheumatic Fever |

| Anemia | Epilepsy | Lupus | Scarlet Fever |

| Anorexia | Fibromyalgia | Measles | Seasonal Allergies |

| Appendicitis | Fractures | Migraine | Stomach Problem/Gastritis |

| Arthritis | Glaucoma | Miscarriage | Stroke |

| Asthma | Goiter | Mononucleosis | Suicide Attempt |

| Bleeding Disorders | Gonorrhea | Multiple Sclerosis | Thyroid Problems |

| Blood Clots | Gout | Mumps | Tonsillitis |

| Breast Lump | Heart Attack | Osteoporosis | Tuberculosis |

| Bronchitis | Heart Disease | Pacemaker | Tumors, Growths |

| Bulimia | Hepatitis | Parkinson’s Disease | Typhoid Fever |

| Cancer | Hernia | Pinched Nerve | Ulcers |

| Cataracts | Herniated Disk | Pneumonia | Vaginal Infections |

| Chemical Dependency /Addiction | Herpes | Polio | Venereal Disease |

| Chicken Pox | High Cholesterol | Prostate Problems | Other: |

| Chronic Fatigue Syndrome | Hypertension | Prosthesis | Other: |

Is there a family history of any of the following?

| Hypertension | Migraines | Arthritis | Asthma |

| Diabetes | Kidney disease | Depression | Heart attack |

| Lung disease | Thyroid disease | High cholesterol | Blood clots |

| Cancer | Stroke | Osteoporosis | |

|Have you had any prior automobile or work related accidents? | Yes  No |

|Explain: |

I verify the above information is accurate.

___________________________________ _____________________

|Patient Signature Date |

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