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Staci Hurt, CRNP
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Patient Intake
Step
1
of
6
16%
Personal Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
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Armed Forces Americas
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State
ZIP Code
Home Phone
*
Mobile Phone
Date of Birth
*
MM slash DD slash YYYY
Sex
Male
Female
Email
*
Employer
Work Phone
Emergency Contact
Emergency Contact Phone
Did a physician refer you to us for today's visit?
*
Yes
No
Physician Name
Referring Physician Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Referring Physician Phone
Is your visit today worker's compensation related?
*
Yes
No
Date of work related injury
MM slash DD slash YYYY
Adjuster/Case manager to contact to verifiy coverage
Adjuster/Case manager Phone
Personal Medical Information Form
PLEASE LIST 3 MAIN PAIN COMPLAINTS (listing the worst area first)
Accident or injury date if applicable
MM slash DD slash YYYY
Injury occurred:
At home
Motor vehicle accident
At work or work-related
Unknown cause (happened spontaneously)
Were you taken off work by a doctor?
*
Yes
No
Doctor’s name
Are you currently working?
*
Yes
No
Date last worked?
MM slash DD slash YYYY
Have you ever been treated for substance abuse (alcohol or drugs)?
*
Yes
No
What substance?
Are you currently or have you ever been enrolled in a Methadone or Suboxone clinic?
*
Yes
No
Name of Methadone clinic/date of last visit/dosage
Have you ever been charged with any crime involving alcohol (DUI), illegal drugs, or prescription medications?
*
Yes
No
If yes, when and what crime:
Have you ever been charged with a crime involving violence, domestic or sexual abuse?
*
Yes
No
Describe
Have you been in jail or court ordered program for a crime?
*
Yes
No
When?
Reason?
Have you ever been treated in a pain management clinic?
*
Yes
No
If yes, please list the physician’s name and when/how long they treated you:
What activities or positions cause your pain to worsen or start?
What positions, activities, treatments improve your symptoms?
How long have you had this pain?
How long has it been this severe?
Brief Pain Inventory
In the past 24 hours, how much relief have pain treatments or medications provided?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Please select the one percentage that most shows how much RELIEF you have received.
How long are you able to walk?
(min/hrs)
How long can you comfortably sit?
(min/hrs)
Average hours slept each night?
(min/hrs)
List your usual chores/activities/hobbies that you enjoy and indicate if you are currently able to perform:
Of the treatements you selected above, list the last time used or performed and their effectiveness:
List your pharmacies and telephone numbers:
Past medications that have helped:
Past medications that were NOT helpful:
What Medications Cause What Type of ALLERGIC Reaction:
Your Past Medical History
Atrial fibrillation
Yes
No
Coronary artery disease
Yes
No
Heart attack (MI)
Yes
No
Stroke
Yes
No
Thin Blood/ bleeding
Yes
No
COPD
Yes
No
Pneumonia
Yes
No
Bipolar
Yes
No
Bowel disease
Yes
No
Diabetes
Yes
No
Overweight
Yes
No
Osteoarthritis
Yes
No
Restless leg
Yes
No
Anemia
Yes
No
Shingles
Yes
No
Irregular heart Beat
Yes
No
Hypertension
Yes
No
Vascular disease
Yes
No
Seizures
Yes
No
Sinus problems
Yes
No
Emphysema/ Bronchitis
Yes
No
Cancer
Yes
No
Type of Cancer
If yes
Anxiety
Yes
No
GI Bleed
Yes
No
High cholesterol/ lipid
Yes
No
Underweight
Yes
No
Rheumatoid Arthritis
Yes
No
Kidney disease
Yes
No
Lupus
Yes
No
Eye Problems
Yes
No
MVP or Heart Valve Problems
Yes
No
Heart Failure
Yes
No
Blood Clots
Yes
No
Migraine Headache
Yes
No
Asthma
Yes
No
Sleep Apnea
Yes
No
Dementia or Alzheimer’s
Yes
No
Depression
Yes
No
Reflux
Yes
No
Thyroid disease
Yes
No
Gout
Yes
No
Osteoporosis
Yes
No
Prostate Problems
Yes
No
Sarcoidosis
Yes
No
Hospitalizations last 6 months
Yes
No
If hospitalized in the last 6 months, explain:
Past Surgical History
Past Surgical History
Operation
Date
Surgeon
Please list all operations and procedures.
Social History
Marital Status
Single
Married
Divorced
Remarried
Seperated
Widowed
Do you smoke?
*
Yes
No
If yes, how much?
At what age did you begin smoking?
IF YOU DO NOT SMOKE CURRENTLY, are you a former smoker?
*
Yes
No
Do you drink alcohol?
*
Yes
No
If yes, what type(s)?
If yes, how many drinks per week?
If yes, how many drinks per month?
Do you currently use illicit substances i.e. marijuana, cocaine, etc?
*
Yes
No
If yes, what?
Family History
Mother is:
Living
Deceased
Medical Problems:
Medical Problems:
Number of brothers
Number of sisters
Medical Problems:
Work/Employment History
Work/Employment History
Employed
Currently off work for now because of this medical condition
Retired
Early retirement because of disability
Temporary disability from worker's compensation
Permanent disability from worker's compensation
Personal or group permanent disability
Applying for group disability or early retirement
On Social Security Disability income
Applying for Social Security Disability
Other
More than one may be marked as needed
Current Medications
Current Medications
Medication/dose/frequency
Doctor
Pharmacy
Name
This field is for validation purposes and should be left unchanged.
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