New Patient Intake - UNM Hospitals

MRN ______________Patient Name: __________________________ DOB:___________________Date of Injury __________ On-The-Job Injury Auto Accident Sports InjuryOther __________________________Is there (or will there be) an attorney involved with this problem? Yes NoReason for Visit (Describe problem/injury/symptoms) (Right or Left side?) ________________________________________________________________________________________________Previous Treatment for this Problem(If none, skip to next section)Physicians/Providers Seen: __________________Arthrogram Date________ Facility____________Bone Scan Date________ Facility____________Casting/SplintingDate _________ Facility_____________Chiropractic/AcupunctureDate _________ Facility_____________EMG/Nerve StudyDate _________ Facility_____________Injection Date _________ Facility_____________MRIDate _________ Facility ____________Physical TherapyDate _________ Facility ____________Vascular StudiesDate _________ Facility ____________X-Rays Date _________ Facility ____________Other Date _________ Explain ______________________________________________________Aggravating Factors:Makes the problem/pain worse?BendingDeep BreathDirect PressureExerciseLiftingMovement of AreaWalkingWeight BearingGraspingOther ____________Type of PainAching Numbness Pins & NeedlesBurning Stabbing SevereDescribe the severity of the pain:0= None /10=Worst0 1 2 3 4 5 6 7 8 9 10Where are your symptoms now?Mark the location of your pain on the picturebelow. Place an X over the area of your pain.Relieving Factors:Makes the problem/pain better?Acetaminophen/Tylenol Muscle RelaxantsAnti-Inflammatory/Ibuprofen Prescription PainAspirinMedicationPhysical TherapyRestCrutchesSlingElastic Wrap Compression HeatIceOther____________________________