- Please read the information for completeness and your safety.
- Please answer each question thoughfully and honestly, but you may be brief. We can discuss issues in more detail during the appointment.
- Please do not race through this form! Please remember that your answers become part of your permanent medical record and the information must be accurate. This is for your safety.
- Please make sure you click the SUBMIT button when you are done.
- Please read these sentences and make sure you agree. If you do NOT agree with them, there will be a place to enter your comments. First, please review these sentences.
First, we need to make sure that there are no significant changes to your medical history.
- If you have a FollowMyHealth account: "I have reviewed the My Info and My Health sections of my FollowMyHealth account and there are no changes." (If you disagree, you will be asked to explain why below.)
- If you do not have a FollowMyHealth account: "Since the time I completed the new patient paperwork or since the last written update to my medical history, I have no new medical conditions, allergies, medications, medical conditions, surgeries, family history, etc." (If you disagree, you will be asked to explain why below.)
Second, we need to make sure that you are not having an emergency condition at this moment.
- "At this time, I do not have: The worst headache of life; double vision; inability to speak or swallow properly; body part gone weak, paralyzed, numb; problem controlling bladder or bowels; losing consciousness, passing out or falling; everything spinning around; new or sudden pain." (If you disagree, you will be asked to explain why below.)
Third, we need to make sure that, if you use pain medications, that they remain appropriate. This sentence is only for patients who are prescribed controlled substances.
- "I did not change the dose of the medication on my own, allow my medications to be lost or stolen, did not receive any pain medications from any other sources, and do not feel impaired or addicted." (If you disagree, you will be asked to explain why below.)
Fourth, we need to make sure that you remain comfortable with your treatments. Remember, you may ask for a second opinion at any time.
- "Treatments are helpful and I do not have concerns about safety, tolerability, or risks of treatment. I do not have side effects of treatment or have mild side effects that are not problematic." (If you disagree, you will be asked to explain why below.)
Fifth and last, we need to review various symptoms that you may be experiencing today. Many of the symptoms would not be addressed by this office, but we need to ask you about them for safety. Yes, this list is long, but it is the standard list. Here is a list of possible symptoms or conditions you may be experiencing at this time: Weight changes, fatigue, sweats, chills, fevers, lymph nodes, swelling, lumps, sores or discharge anywhere on body, skin problems, easy bruising. Neck: stiff, pain, tender, glands. Ears: pain, hearing loss, ringing, hearing aid. Nose: bleeding, colds, obstruction, septum problem. Mouth: dental problem, bleeding, sores, sore throat, bad taste. Eyes: double vision, tearing, blind spots, pain, eyelid droop, blurry, cataracts. Breathing: asthma, short of breath, cough, blood, TB, COPD, bronchitis. Heart: chest pain, palpitations, passing out, blood pressure, murmurs, mitral valve prolapse, varicose veins, Reynaud's, anemia, bleeding problems or clots. Immune: frequent infections, constant colds or flus. Genital: hernia, pain, STDs, HIV, painful intercourse, erectile dysfunction, pregnancy or planning, breast, tenderness. Abnormal bleeding or periods. GI: appetite, abdominal pain, GERD, nausea, vomiting, jaundice, hepatitis A/B/C, constipation, diarrhea, hemorrhoids, change in bowel habits or change in stools. Urinary: urgency, frequency, pain, blood, stones, infections, kidney, retention (can't go), incontinence (can't hold), discharge. Endocrine: diabetes, thyroid, infertility, acne, goiter, heat/cold intolerance, tremor, palpitations. Neuro: stroke, seizure, Alzheimers, Parkinsons, migraine, meningitis, MS, brain injury, neuropathy, muscles, spinal cord, weakness, cramps, atrophy. Mood/Social: nervous, anxiety, mood swings, depression, crying, sleeping, libido, suicidal thoughts, suicide attempts, panic. Alcohol abuse, smoking, drug abuse. Now that you have reviewed that long list, here is the fifth sentence to review for safety.
- "I do not have any new symptoms as listed above. I am not suicidal; do not have significant depression; am not pregnant, breast feeding, or trying to become pregnant; do not drink alcohol or use illicit drugs with my medications. There has been no major or sudden change in my condition(s). The problem(s) involve the same body parts." (If you disagree, you will be asked to explain why below.)
Now that you have read these five important sentences, please decide if you agree or disagree with them. If you disagree or need to explain anything, please do so below.