Physical Medicine Consultation & Evaluation to Utah Pain and Rehab - Integrated Healthcare and Pain Management in Ogden Utah

Physical Medicine Consultation & Evaluation to Utah Pain and Rehab - Integrated Healthcare and Pain Management in Ogden Utah

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Initial Physical Medicine Consultation & Evaluation

Last Name: First Name: Middle Initial: Address: City: State: Country: Zip: Home Phone: Work Phone: Occupation: Employer: SS#: Date of Birth: Insured Name: Spouse Name: Ins.#: Insurance Co. Name: Insurance Co. Phone Number: Insurance ID# and Group #: Insured name, D.O.B & SS# (if other than patient): 2nd Insurance name, phone #, ID# and Group #:	2nd Insured name, D.O.B & SS# (if other than patient): Emergency contact and referred by: Patient Symptoms Describe in detail the reason for your visit: When did the problem start?: Is this related to a: Motor Vehicle Accident Workmans Comp List Areas Involved: List Symptoms You Experience: List Medications Used: What makes it better and worse: Who has treated or evaluated this problem in the past?

If 0% represents no pain, and 100% represents unbearable pain, please rate your pain by selecting when your pain is: At its worst, At its best, and Most of the time… At its worst: At its best: Most of the time: What makes it better: What makes it worse: Social & Employment History Marital Status: Current Employment: Full Time Part Time Job Duties / Activity Required: Tobacco: Yes None Alcohol: Yes None What Supplements / Over-the-Counter Remedies have you tried: How Much/How Often/Why Used:	Medical Allergies List any allergies and associated symptoms: Medical History & ROS For a current medical problem or a symptom you are currently experiencing. Please identify family members with these problems or those with similar symptoms. Family Member & Relationship: Problem(s): No Family History or Current Family Medical Problems: None Please check any of the following problems you currently or previously experienced. Previous surgeries including dates Previous auto accidents, please include dates and details Previous Falls/ Injuries, please include dates and details Security Code: * Reload Image

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