PATIENT INFORMATION
Primary Care Physician
First Name
Middle Name
Last Name
Is this your legal name?
Yes
No
If not, what is your legal name?
(Former name):
Salutation
Mr.
Miss.
Mrs.
Ms.
Marital status (checkone)
Single
Divorced
Widowed
Married
Separated
Significant Other
Birthday
Age
Sex
M
F
Address
City
State
Zip Code
Cell phone
Home Phone
Social Security Number:
Occupation
Employer
Employer Phone Number:
Choose your preferred clinic location:
Bozeman
Billings
Helena
Missoula
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Chose clinic because / Referred to clinic by (please check one)
Dr. Referral
newspaper
Hospital
Family/Friend
TV
Dinner Event
Mailer
Email
*
Spouse’s Name
Please List any other family members/friendsinvolved in your health decisions
Insurance Name
Insurance Type
PPO
HMO
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address)
The above information is true to the best of my knowled
Patient/Guardian signature:
Clear
Date Signed
What is your major complaint?
How long have you had this problem?
Before you began having this problem was there an earlier condition, accident, or injury that could have brought this problem about? f so please describe
Have you seen a M.D., P.T., or a D.C. for this problem?
Doctor’s Name.
Specialty.
Year(s) Seen.
Doctor’s Name.
Specialty.
Year(s) Seen.
Doctor’s Name.
Specialty.
Year(s) Seen.
How does this problem interfere with your daily day life?
Have you been worried about getting this problem resolved?If yes, please describe
On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain?
1
2
3
4
5
6
7
8
9
10
Please list all of your medications to review with the doctor.
General
Fatigue, tirednes
Weakness
Chills
Fever
Night sweat
Appetite change
Lived in foreign country
Unexplained weight loss
Unexplained weight gain
Generalized pain
Unable to tolerate heat
Unable to tolerate cold
Sedentary lifestyle
Active lifestyle
Other
Neurological
Fainting spells
Seizures
Paralysis
Dizziness
Tremor
Chronic headaches
Poor balance
Fractured back or neck
Numbness of face / arm / leg
Peripheral Neuropathy
Stroke or Mini –stroke
Other
Psychiatric
Depression
Anxiety (abnormal)
Panic attacks
Alzheimer’s
Confusion (abnormal)
Hospitalized for nervousness
Substance abuse
Anorexia
Other
Cardiac
Angina (chest pain)
Rapid heartbeat
Past heart attacks
Heart murmur
Congestive heart failure
High blood pressure
Aortic aneurysm
Other heart problem
Pacemaker
Defibrillator
Other
Vascular
Leg pain walking over 1 block
Leg pain walking less than 1 block
Pain in legs while at rest
Blood clots in legs
Deep
Superficial
Cold feet or hands
Amputation of toes
Amputation of feet or legs
Peripheral vascular disease
Ulcers of lower legs
Varicose veins
Aneurysm of arteries
Other
Gastrointestina
Diarrhea
Constipation
Stool changes
Bowel habits changes
Hemorrhoids
Indigestion
Ulcers
Irritable bowel
Colon polyps
Cramps/ pains
Cancer of the stomach or bowel
Diverticulitis
Other
Genitourinar
Hesitancy / urgency of urine
Need to urinate often at night
Loss of bladder control
Difficult urination
Renal failure
Impotence
Current Dialysis
Renal transplant
Prostate enlargement
Cancer of bladder/ kidneys
Other
Blood & Lymph System
Anemia
Blood disease
Transfusions
Leukemia
Bone marrow test
Long term Coumadin use
Blood clotting problems
Other
Eyes, Ears, Nose & Throat
Pain
Hearing loss
Polyps
Vertigo
Ringing in ears (tinnitus)
Sinus infections
Deafness
Other
Musculoskeleta
Arthritis
Joint swelling
Joint stiffness
Muscle aches
Muscle weakness
Leg cramps
Other
Skin
Rashes
Tumors
Sensitivity to sunlight
Malignant melanoma
Squamous cell carcinoma
Basal cell carcinoma
Easy bruising
Fungal infections
Non-healing sores
Excessive rough or dry skin
Other
Endocrine
Thyroid problems
Diabetes –Type 1
Diabetes –Type 2
Abnormal Organ
Hepatitis
Cirrhosis (Liver)
Gallbladder disease
Height:
Weight: