Welcome to Hamilton Clinic / Evansville Rehabilitation

Patient Information

Last Name_______________________    First Name___________________ M.I._____

Street Address__________________________    City_________________    State____    Zip_________

Home Phone(____)____-_________    Marital Status: Single    Married    Widow    Divorced

Gender_______    Social Security #_____-_____-_________    Date Of Birth____/_____/________

Employer_____________________________    Occupation____________________________

Employer Address______________________________________    Work Phone(____)____-________

Emergency Contact____________________________   Contact Phone(_____)_____-________

Primary Care Physician____________________________    Date of Last Visit_________________

You were referred to us by:__________________________________________

Insurance Information

Primary Insurance

Insurance Company__________________________________________     Insured Name_________________

Insured Employer____________________    SS#___________________    Group #________________

Insured Date of Birth____/_____/_____    Relationship to insured: Self    Spouse    Child    Other

Secondary Insurance

Insurance Company__________________________________________     Insured Name_________________

Insured Employer____________________    ID#___________________    Group #________________

Insured Date of Birth____/_____/_____    Relationship to insured: Self    Spouse    Child    Other

If your condition is accident related, will a claim for workmen's compensation be filed?  Yes / No

 I understand and agree that health and accident insurance policies are an arrangement between myself and the insurance carrier and that I am personally responsible for payment of any and all services, covered or non-covered.  I hereby authorize Evansville Rehabilitation to furnish information to insurance carriers and other health care providers concerning my treatment and I hereby assign to the practitioners all payments for services rendered to my dependents or myself.

Patient Signature__________________________________    Date____________________

Parent/ Guardian's Signature (if patient is a minor)__________________________    Date____________

Hamilton Clinic / Evansville Rehabilitation Health Questionnaire

Patient Last Name____________________    Current Date_____________

1)Describe all of your current health problems:

2)List any other doctors that you have seen and list treatments  received and results obtained:

3)List all diagnostic testing (x-rays, MRI's, blood and urine analysis, etc) that you have received:

4)List all surgeries you have had and the corresponding dates

5) Please mark with an "X" the following which you have been taking within the past 2 months: ___Vitamins     ___Stomach Medicine    ___Birth Control Pills     ___Laxatives   ___Pain medicine    ___Cold/Cough medicine    ___Hormones    ___Appetite curb pills    ___Thyroid tablets    ___Iron/B12    ___Anti-depressants    ___Cortisone    ___Heart drugs    ___Sleeping pills    ___Insulin    ___Diuretics    ___Barbiturate tabs    ___Others______________________    ___Others______________________

6) Is your current condition accident related?  Y    N        Date of Accident_____________________

Type of accident    Auto    Work/Job    At home        Other_______________

7) Have you ever been in an automobile accident?

_____Past Year        ____Past 5 Years        ___Over 5 years ago        ___Never

8)Have you ever sustained an industrial injury or any other injury for which you received treatment?   When?

9)Please check the following conditions that you have or have had:   ____AIDS    ____Anemia    ____Arthritis    ____Cancer    ____Diabetes    ____Epilepsy    ____Hardening of the arteries    ____Heart attack    ____High blood pressure    ____Hypoglycemia    ____Multiple Sclerosis    ____Parkinson's Disease    ____Polio    ____Rheumatic Fever    ____Stroke    ____Tuberculosis    ____Venereal Disease

Family History

Please Mark with an X all symptoms:

Head:   ___Unusually frequent headaches    ___Unusually severe headaches    ___Head fells heavy    ___Vertigo    ___Light-headedness    ___Loss of Smell    ___Loss of Taste    ___Loss of balance    ___Previous head trauma

Neck:    ___Neck pain with movement    ___Swelling in neck    ___Stiff Neck    ___Pinched Nerve in neck    ___Neck feels out of place    ___Muscle spasms in neck    ___Abnormal sounds in neck    ___Previous neck injury

Shoulders:    ___Pain in shoulder (right or left)    ___Pain across shoulders    ___Tension in shoulders    ___muscle spasms in shoulders    ___Can't raise arm above shoulder level    ___Can't raise arm over head

Arms and Hands:    ___Pain in upper arm    ___Pain in forearm    ___Pain in hands    ___Pain in fingers    ___Sensation of pins and needles (__in arms  __in fingers)    ___Fingers go to sleep    ___Hands cold    ___Swollen finger joints    ___Sore finger joints    ___Loss of grip strength

Mid Back:    ___Pain between shoulder blades    ___Mid-back pain    ___Pain from front to back    ___Pain over kidney area    ___Muscle spasms in mid back

Low Back:    ___Low back pain    ___Low back feels out of place    ___Muscle spasms in low back

Hips, Legs & Feet:    ___Pain in buttocks    ___Pain down leg    ___Knee Pain    ___Leg cramps    ___Sensation of pins and needles    ___Numbness in leg    ___Numbness in toes    ___Cold feet    ___Swollen ankles    ___Swollen feet

Cardiovascular:    ___General swelling    ___Swelling in legs    ___Swelling in face    ___Swelling around eyes    ___Chest pain    ___Pounding heartbeat    ___Heart "jumps"    ___Rapid heartbeat    ___Irregular heartbeat    ___Blue or purple skin    ___Fainting    ___Hypertension

Hair, Skin, Nails    ___Baldness    ___Dry scalp    ___Oily scalp    ___Eczema    ___Psoriasis    ___Itchy skin    ___Rough, scaly skin    ___Dry skin    ___Oily skin    ___Yellow skin    ___Bruise easily    ___Pale skin    ___Paper-thin nails    ___Nail biting

Eyes:    ___Blurred vision    ___Double vision    ___Eyes fatigue easy    ___Excessive tearing    ___Lack of tearing    ___Light bothers eyes    ___Excessive itching    ___Pain in eyeball    ___Periods of blindness in eye

Ears:    ___Loss of hearing    ___Pain in ears    ___Discharge from ears    ___Vertigo    ___Ringing in ears

Nose/Nasopharynx/Sinuses:    ___Unusual nasal discharge    ___Nosebleeds    ___Pressure over eyes    ___Pressure under eyes    ___Obstruction of nose    ___Frequent colds    ___Sinusitis    ___Nasal allergies    ___Loss of sense of smell    ___Any trauma to nose

Mouth & Throat:    ___Pain in mouth    ___Pain in throat    ___Bleeding gums    ___Cavities    ___Abscessed teeth    ___Dentures    ___Difficulty in swallowing    ___Changes in voice

Respiratory:    ___Shortness of breath    ___Difficulty breathing while lying down    ___Difficulty sleeping while lying down    ___Dry cough    ___Productive cough    ___Coughing up blood    ___Wheezing

Gastrointestinal:    ___Poor appetite    ___Constant nibbling    ___Indigestion    ___Stomach upsets from food    ___Stomach upsets from liquid    ___Stomach upsets from medicines    ___Abdominal Pains    ___Stomach gas before meals    ___Stomach gas with meals    ___Stomach gas after meals    ___Change in bowel habits    ___Diarrhea    ___Constipation    ___Hemorrhoids

Genitourinary:    Urination is Frequent/Infrequent?    Amount is High / Low?    ___Need to get up at night to urinate    ___Difficult to start/stop urination    ___Painful urination    ___Dribbling    ___Blood in urine    ___Cloudy urine    ___Lack of bladder control

Female Only:    ___Painful period    ___Spotting    ___Vaginal discharge    ___Premenstrual symptoms    ___Irregular periods    ___Lumps in breast    ___Wear an IUD    ___#of pregnancies    ___# of deliveries    ___# of Vaginal deliveries    # of C-sections    ___complicated deliveries

Male Only:    ___Impotence    ___Testicular swelling / pain    ___Abnormal discharge

General Health Questions:    ___Smoke    ___Other Tobacco use    ___Alcohol consumption    ___Coffee/tea

My diet is    ___balanced    ___not balanced

My rest is     ___sufficient    ___insufficient   

My recreation is     ___sufficient    ___insufficient

My family stress is    ___severe    ___moderate    ___minimal    ___none

How do you like your work?    ___I like it very much    ___Its okay    ___I dislike it

My job stress is    ___severe    ___moderate    ___minimal    ___none

I have experienced    ___nervousness    ___irritability    ___fatigue    ___depression    ___run-down feeling    ___craving for sweets    ___craving for salt

Chief Complaint and History of Present Condition               Patient Name________________________

1. Where is your pain (indicate on figures)

2. What type of pain is it? ___Sharp    ___Ache    ___Dull    ___Burning    ___Throbbing

3. Rate pain on a scale of 0-10 (10 being severe pain):    _____

4. How long have you had this pain?_______________________________________

5. What makes the pain worse?___________________________________________

6. What makes the pain better?____________________________________________

7. Does the pain travel?____    If so, where?____________________________________

8. Is pain worse at any particular time of day? _________________________________________

9. Date of onset___/____/_____        Date of same or similar symptoms____/____/____