Multistep

Patient Intake Form

Today's Date (Fecha de Hoy) * Is this a work comp injury? (¿Es una lesión de compensación laboral?) * YesNo If work comp injury, explain (Si es compensación laboral, explique) Employer (Empleador) Job Title (Título de Trabajo) When is your next scheduled appointment with your referring doctor? (¿Cuándo es su próxima cita programada con su médico de referencia?)

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Patient Information (Información del Paciente)

Name (Nombre y Apellido) * Sex (Sexo) Male (Masculino)Female (Femenino)Other (Otro) Home Address * Street Address * City * State * ZIP Code * Email Telephone No: (No. De Teléfono:) * Birth Date (Fecha De Nacimiento) * Age (Edad) Social Security #: (No. De Seguro Social)

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Health Insurance Information (Información del Seguro Médico)

Name of Health Insurance Company (Nombre de la compañía de seguros de salud) Member ID (Número de Miembro) Group Number (Número de Grupo) Health Insurance Phone Number (No De teléfono de Compañía De Seguro Medico) Are your current symptoms the result of (Son sus síntomas actuales el resultado de) * An Injury / Accident (Accidente / Lesión)Illness (Enfermedad)Developed over time (Desarrollado con el tiempo) Please explain (Por favor explique) What treatments have you had for this injury? (¿Que tratamiento ha recibido para esta lesión?) * Medications (Medicamentos)Physical Therapy (Fisioterapia)Acupuncture (Acupuntura)Injection (Inyección)Surgery (Cirugía)Other (Otro)

Exams Performed (Exámenes realizados)

X-Rays (Rayos X) YesNo MRI YesNo Supports / Braces? (¿Soportes / Tirantes?) YesNo

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Past Medical History (Historial Médico Pasado)

Prior accidents / injuries? (¿Accidentes o lesiones previas?) * YesNo Have you ever had any surgeries? (¿Alguna vez has tenido alguna cirugía?) * YesNo

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Personal Medical History and Conditions (Historial médico personal y condiciones)

Do you have or have you had any of the following conditions? (¿Tiene o ha tenido alguna de las siguientes condiciones? Heart Disease (Enfermedad del corazón) Yes (Si)No Diabetes YesNo High Blood Pressure (Hipertensión arterial) Yes (Si)No Arthritis (Artritis) Yes (Si)No Cancer (Cáncer) Yes (Si)No Asthma (Asma) Yes (Si)No Blood Disorder (Trastorno de la sangre) Yes (Si)No Other (Otro) YesNo Do you have a positive family history for any of the above? (¿Tiene antecedentes familiares positivos de alguno de los anteriores?) YesNo

List all current medications you are presently taking (Enumere todos los medicamentos actuales que está tomando actualmente) *

Please list all current prescription and over the counter medications and reason for taking. Write "none" if not applicable. (Enumere todos los medicamentos recetados y de venta libre actuales y la razón para tomarlos. Escriba "ninguno" si no corresponde.) Are you Allergic to any medication? (¿Eres alérgico a algún medicamento?) YesNo Do you have any Allergies? (¿Tienes alguna alergia?) YesNo Have you ever had an EMG/NCS test in the past? (¿Alguna vez ha tenido una prueba EMG / NCS en el pasado?) YesNo

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Review of Systems (Revisión de Sistemas) *

Do you have or have you had any of the following? (¿Tiene o ha tenido alguno de los siguientes?) Muscle WeaknessTremorsNumbness/Tingling/ Burning SensationPain/Muscle Pain/Myalgia/Back Pain/Neck PainJoint Pain / SwellingDecreased Range of MotionMuscle Cramps/Leg Cramps/Muscle SpasmsLoss of Strength/Difficulty with grip

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Social History (Historia Social)

Do you smoke? (¿Fuma?) * YesNo Do you drink alcohol? (¿Bebe alcohol?) * YesNo

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List your current complaints of pain *

NeckShoulder LeftShoulder RightArm LeftArm RightElbow LeftElbow RightWrist LeftWrist RightHand LeftHand Right Lower backHip LeftHip RightThigh LeftThigh RightKnee LeftKnee RightAnkle LeftAnkle RightFoot LeftFoot Right Do you have pain at night time and/or does your pain wake you up at night? (¿Tienes dolor por la noche y / o tu dolor te despierta por la noche?) * YesNo Do you experience weakness? (¿Experimenta debilidad?) * Hand LeftHand RightFoot LeftFoot RightN/A Do you experience numbness? * Hand LeftHand RightFoot LeftFoot RightN/A Do you experience tingling? (¿Experimenta hormigueo?) * Hand LeftHand RightFoot LeftFoot RightN/A Pain increases with (El dolor aumenta con) * Pain relieved by (El dolor se alivia con) *

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