Download PRIME Podiatry Intake Form

PRIME (Postural Restoration® Integrative Multidisciplinary Engaged) INTAKE FORM:
Heidi Wise, OD, FCOVD
Ron Hruska, MPA, PT
Paul Coffin, DPM
Margo Schenll, DDS
David Drummer, DPT, PRC
Torin Berge, MPT, PRC
Lori Thomsen, MPT, PRC
Jason Masek, MSPT, CSCS, ATC, PRC
Please fax your last three eye exam records (the complete exam records including eye health, not just the refraction)
to us. Your most recent eye exam must be within the last 18 months.
Patient Name (F) _________________(MI)_______(L)________________________Preferred Name_________________
Address___________________________________________City____________________State/Zip _________________
Social Security Number_______________________Date of Birth____________________
Email Address_________________________________Home Phone (
Employer____________________________________ Work Phone (
Male
)________________Cell(
Female
)_______________
)_________________ Ext.___________________
Spouse’s Name_______________________________ Spouse’s Employer______________________________________
Person Responsible for Account_________________________________Address_________________________________
Emergency Contact and Phone number__________________________________________________________________
Referring Therapist, Doctor, or Dentist_______________________________City/State____________________________
Primary Eye Doctor_________________________________City/State__________________Phone__________________
Primary Physician__________________________________City/State___________________Phone_________________
Insurance Provider_________________________ Dental Insurance Coverage (Y/N) Company_____________________
Insured’s Name and Employer__________________________________________________________________________
Insured’s Date of Birth_________________________ Insured’s Social Security Number___________________________
If in college, are you a full time student? (Y/N) Name of School_______________________________________________
My main reason for being seen is:________________________________________________
This began:______________
What is it you want to do that you can’t do
now?____________________________________________________________
Previous Surgery(s) or Significant
Trauma:___________________________________________________________________________________________
__________________________________________________________________________________________________
Chief complaints and reasoning behind your need to come to PRI Vision Clinic. Examples: Headaches, dizziness, vertigo,
back pain, etc.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Medical History: Have you suffered from any of the following:
a.
b.
c.
d.
Head/Brain injury?
Whiplash injuries?
Concussions (diagnosed or undiagnosed)?
Lost consciousness?
Y
Y
Y
Y
N
N
N
N
If yes to any of the above, please briefly describe what kind of injury and when:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Dental – TMJ History
e.
f.
g.
h.
i.
Are you presently wearing a mouthpiece?
Do you have OR have you had braces?
Do you have clicking, popping or jaw opening limitations?
Do you clench or grind?
Do you have jaw or facial pain?
Y
Y
Y
Y
Y
N
N
N
N
N
Please summarize issues that you possibly have had with your eyes. Example: Pain behind eyes, lasik surgery, blurry
vision, etc.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Without rotating or moving your body, can you turn your head to each direction?
Do you feel limitations to either direction? Y N
If yes, which direction? _____________________
Y
N
Please circle what you put over or on your eyes (please circle all that apply):
a.
b.
c.
d.
e.
Nothing
Contacts
Glasses
Sunglasses
Bifocals:
Lined
Hand Dominance (please circle one):
No line/Progressive
Right-handed
Are you seeing a physical/occupational therapist?
Y
If yes, who? ______________________________
Left-handed
N
Is there anything else significant about your physical or health history we need to be aware of?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Do you have, or have had, any of the following:
GENERAL HEALTH:
Diabetes?
YES NO
Weight Loss?
YES NO
Allergies?
YES NO
Type? _____________________
Are you allergic to Latex? ______
Digestive Disease?
YES NO
Metal Implants?
YES NO
Heart Problem?
YES NO
Depression?
YES NO
Seizures?
YES NO
Pregnant (Currently)?
YES NO
Cancer?
YES NO
High Blood Pressure?
YES NO
NECK/JAW/HEAD:
Do you experience facial pain? YES NO
Do you feel a click or pop when you open or
close your mouth?
YES NO
Migraines/Headaches
YES NO
Do you feel pain in the front of your ear, or
ear “fullness” or “ringing”? YES NO
Do you feel tension in your neck or at
the base of your skull?
YES NO
Head Trauma/Whiplash
YES NO
Concussion
YES NO
Do you wake up with a dry mouth?
YES NO
LUMBO/PELVIC/FEMORAL:
Do you ever experience small amounts of
urine leakage when you cough, sneeze,
laugh, lift or exercise?
YES NO
Do you experience pain, discomfort or
pressure in your pelvic area when sitting
or standing?
YES NO
Do you experience hip or groin pain?
YES NO
Do you experience low back pain?
YES NO
Do you experience frequent trips to the bathroom?
YES NO
BREATHING:
Do you still feel tired after a full night of sleep?
YES NO
Do you have asthma?
YES NO
Do you have to sleep in an upright position?
YES NO
Have you been diagnosed with sleep apnea?
YES NO
Do you snore?
YES NO
Do you use and inhaler?
YES NO
Do you have difficulty breathing with simple activity,
i.e.: going up steps?
YES NO
Have you been diagnosed with sleep apnea?
YES NO
FEET:
Do you have flat feet?
YES NO
Do you have pain on the bottom of your feet
when you are standing?
YES NO
Do you use orthotics, heel lifts, or any other
foot inserts in your shoes? YES NO
Does one of your feet turn out more than
the other?
YES NO
Do you feel unstable on one or both of your
feet or legs?
YES NO
Do you have a large bony bump near either of you big
toes?
YES NO
VISION:
Lazy Eye
YES NO
Eye Turn
YES NO
Double Vision
YES NO
Intermittent Blurred Vision YES NO
Lose place while reading
YES NO
Eyestrain
YES NO
Light Sensitive
YES NO
Retinal Detachment
YES NO
Macular Degeneration
YES NO
Glaucoma
YES NO
Cataracts
YES NO
Eye Surgery
YES NO
Difficulty at the computer YES NO
Do you occasionally bump into objects while walking?
YES NO
Do you have difficulty driving at night? YES NO
Do you have lateral leg & ankle strain, back tightness, or
pain at the bottom of one or both feet? YES NO
What type?___________________________
Please list all medications you are currently taking and
for what condition:
__________________
_____________________
__________________
_____________________
__________________
_____________________
PLEASE INDICATE ON THE PICTURES TO THE RIGHT THE
LOCATION OF YOUR ISSUE(S)
&
PLEASE INDICATE YOUR LEVEL OF DISCOMFORT AT ITS
WORST AND BEST ON THE SCALE BELOW
0 1 2 3 4
0 = NO DISCOMFORT
DISCOMFORT
5
6
7
8
10 = EXTREME
9 10
Number of hours/day on a computer: for work______
For pleasure______
When was your last eye examination? ___________
Do you wear glasses now? NO YES
When? ______________________
Do you wear contact lenses at this time? NO YES
When?_______________________________
I am happiest when I participate in these activities:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I am here today
because:___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What is it you want to do that you can’t do
now?_____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Patient-Specific Functional Scale INITIAL or FOLLOW UP
1. Please identify up to 3 important activities that you are unable to do or are having difficulty with as a
result of your __________________________________________________________problem.
**Consider these examples: getting dressed, walking your dog, yard work, sports activities, etc.
Activity
1.
Score
√ Most Limited
2.
3.
0
Please score each activity in the above chart using the scale below:
1
2
3
4
5
6
7
8
9
10
Able to perform
activity at the same level
Unable to
perform activity
as before injury or problem
PRIME Podiatry Intake Form
Explain you reason for seeing the doctor today?
_____________________________________________________________________________
*If you’ve had changes in your medical history such as medications, hospitalizations, or illnesses, please notify us.
Is the problem a result of an accident or injury? NO
YES, Date______________________
Explain:_______________________________________________________________________
Have you had injuries or surgeries?
NO
YES
Explain_______________________________________________________________________
Have you seen another doctor for this condition?
NO
YES, Who?_____________________
What diagnosis and treatment were given?__________________________________________
_____________________________________________________________________________
Is the problem present: ALL OF THE TIME
SOME OF THE TIME
COMES AND GOES
How long have you had symptoms?________________________________________________
Is the pain associated with a certain situation?_______________________________________
Standing
YES
NO
Getting up in morning YES
NO
Walking
YES
NO
Keeps awake at night YES
NO
Sports YES
NO
Specific Shoes
YES
NO
Running
YES
NO
Does your job require standing/walking for long periods of time?
YES
NO
Does anything make the symptoms better?__________________________________________
Does anything make the symptoms worse?__________________________________________
What kind of shoes do you wear for everyday?_______________________________________
Sports? (brand if known)_________________________________________________________
Do you participate in (circle all that apply):
Walking
Tennis
Running
Golf
Baseball
Volleyball
Basketball
Gymnastics
Soccer
Dance
Hockey
Biking
Football
Track
Cross Country
Marathons
Triathlons
Other________________
On what level?
Occasional
For Exercise
For Competition
School Team
College
Professional
Are you currently training for a special competition? NO
YES_________________________
What % of the time do you wear the following footwear?
Athletic_______%
High Heels_______%
Dress Shoes_______% Casual Dress_______%
Sandals_______%
Work Boots_______% Barefoot_______%
Do you wear Orthotics?
NO
Flip Flops_______%
Other________________
YES, from where?_____________ What kind?______________
Circle the pain you are having:
Burning
Throbbing
How severe is the pain?
Aching
Gnawing
Stabbing
Shooting
Mild 1 2 3 4 5 6 7 8 9 10 Severe
Mark the location of you problem:
Circle any that apply:
Bunions
Hammertoes
Frequent ankle sprains
Callouses
Achilles pain
Feet roll in/out
Back pain
Wide feet
Swelling in feet, lower legs
Narrow feet
High arches
Knee or hip pain
Flat feet
Frequent cold feet
Knee or hip replacement
Frostbite
Burning feet
Difficulty finding shoes that fit
Intoe
Outtoe
Family history of foot problems
Problems with feet, special shoes in childhood
Numbness
ASSIGNMENT OF BENEFITS STATEMENT &
CONSENT FOR TREATMENT
I __________________________________, voluntarily give my consent to PRIME Integration to
evaluate and treat my condition(s).
Authorization For Release Of Medical Information And Assignment Of Benefits
For consideration of services rendered by the PRIME Integration staff. I hereby guarantee
payment of all charges incurred by above named patient at the time of service. I further
authorize this office to release/receive any information acquired in the course of my
examination and treatment to any other physicians, hospitals, or clinics.
I authorize PRIME Integration to release information regarding my care/treatment to the
following family members (spouse, children, siblings):
___________________________________________________________________________
___________________________________________________________________________
______________________
It is the patient’s responsibility to keep personal items with them at all times.
I also authorize PRIME Integration to photograph me for the purpose of identity in my medical
records not to be shared with any outside sources.
I have answered all of the above questions truthfully and give permission to diagnose and treat
my condition.
I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR CHARGES
INCURRED DURING MY PARTICIPATION IN THE PRIME PROGRAM.
PATIENT NAME (PLEASE PRINT)____________________________
PATIENT SIGNATURE (GUARDIAN IF PATIENT IS A MINOR)
DATE SIGNED_____________________________________________
RESPONSIBLE PARTY (if other than patient)_______________________________________