Microsoft word - ot patient intake form

PATIENT INTAKE FORM
In order to minimize your wait time and maximize your experience, please complete this questionnaire prior to your appointment and bring it with you. We realize this is a lengthy form but assure you it is all important information and will be kept confidential. Check all the factors that apply to your current lifestyle and eating habits: ___Significant other or family members have special dietary needs or food preferences ___Eat more than 50% of meals away from home ___Emotional eater (eat when sad, lonely, Smoking:
How many years? _________ Packs per day:________ OrthoTrim exclusively provided by KneeCenters Alcohol Intake:
How many drinks currently per week? (1 drink = 5 oz wine, 12 oz beer, 1.5 oz spirits) _______________________________________________________________________________ Exercise:
Current exercise program: Activity (list type, number of session/week, and duration of activity) ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ List any problems that limit activity:__________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Would you be interested in an appointment with our physical therapist for a personalized exercise program and review? _______________________________________________________________ Sleep/Rest:
Average number of hours you sleep per night? __________________________________________ Do you have known adverse food reaction or sensitivities? If yes, describe symptom: ___________________________________________________________ ________________________________________________________________________________ If yes, list all: ___________________________________________________________ OrthoTrim exclusively provided by KneeCenters ________________________________________________________________________________ Please indicate which weight loss medications you have tried in the past: If you checked any of the above medications, please indicate when you took the medication, for how long, how much weight (if any) you were able to lose, and why you stopped. Medication
Duration (how long did
Reason for stopping
you take)
weight loss
OrthoTrim exclusively provided by KneeCenters Medical History
Type I Diabetes/Insulin Dep (Uncontrolled) Type II Diabetes/Adult Onset (Controlled) Dysmenorrhea (excessively painful menses) Abnormally elevated liver function tests Stress urinary Incontinence (leaking urine with OrthoTrim exclusively provided by KneeCenters Surgical History:
Please list any surgeries you have had or indicate if you have not had any. Review of Systems – to be completed by patient
General:
□ Weight gain last 6 mos
□ Irritable
HEENT:
□ Headaches

CV:
□ Chest pain

Resp:
□ Cough
□ Difficulty breathing with exertion/activity OrthoTrim exclusively provided by KneeCenters
Female GU/Gyn:

Musculoskeletal:
□ History of broken bone as an adult, if so which: _______ Neurologic:
□ Headaches

Psychiatric:
□ Anxiety/Excessive worry
□ Problems with relationships □ Change in Job in last two years □ Death of close family/friend in last two years
Endocrine:
□ Excessive thirst
□ Excessive Urination (frequency or quantity) □ Enlarged breasts for males □ FerƟlity problems
Skin:

Hematology:
□ Anemia
OrthoTrim exclusively provided by KneeCenters Allergies:
□ MedicaƟons. If so, please list medication and reactions: ___________________________________________ ______________________________________________________________________________ Iodine: ___ No known allergies:___ Please list below any and all mediations/vitamins you are taking: Example: Lipitor 10mg one tablet daily at bedtime ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ OrthoTrim exclusively provided by KneeCenters

Source: http://orthotrim.com/patient_form.pdf