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PAIN, HEALTH & NUTRITION SCREENING
Date of evaluation:
*
+
Patient Name (First and Last):
*
Prescriber
*
Ademola Ogunruku
Dr. Alena Antohina
Amy Kowalewski
Andrea Owes
Aphie Amams
Callister Ibe
Christelle Cousseillent
Dr. Crystal Fitzpatrick
Elina Kay
Georgia Chijioke
Gloria Akuuna
Dr. Ije Okeke
Grace Nwokike
Dr. Indira Shah
JoAnne Piaggio
Jobin Kallacheril
Kingsley Oyem
Laura Velli
Linda Milano
Olusolape Akinyemi
Marly Jiby
Dr. Michael Barness
Stacy Grissett
Dr. Victor Grosu
Dr. Xueming Ye
Unsure of Providers name
West Palm Beach
Information below to be completed by client/guardian prior to meeting with Provider during initial intake
HEALTH AND MEDICAL STATUS
Have you had a physical exam within the last year?
*
Yes
No*
HEALTH HISTORY
*
Yes
No
Problems with vision
Yes
No
Problems with hearing
Yes
No
Problems with speech
Yes
No
Broken bones or dislocations
Yes
No
Muscle or joint injuries
Yes
No
Neck or back injuries
Yes
No
Chest Pain
Yes
No
Heart problems
Yes
No
High blood pressure
Yes
No
Problems breathing
Yes
No
Asthma treatment (past 3 years)
Yes
No
Seizure treatment (past 2 years)
Yes
No
If you are experiencing any of the health problems listed above, are you being treated for this problem?
*
Yes
No*
Please list any operations or medical procedures:
Name of your primary care physician:
*
Please list current and past (within the past 6 months) medications:
*
Medication and Environmental allergies (bees, pollen, etc.):
*
PAIN SCREENING
Are you currently experiencing any pain?
*
Yes*
No
Do you experience prolonged pain at other times?
*
Yes*
No
Please rate the level of pain you are experiencing, if any:
*
None
Mild
Moderate
Severe
Worst Possible
Where is the pain located?
*
Head
Legs
Neck
Feet
Arms
Chest
Back
Other, describe
Other, describe
What impact does the pain have on your life?
*
N/A
None
Some*
Significant*
If it has had an impact, are you being treated for this problem?
*
N/A
Yes
No*
NUTRITION SCREENING
Have you experienced weight loss or gain of 10 pounds or more in the last three months?
*
Yes*
No
Have there been any changes in your appetite in the past three months?
*
Yes
No
Has a doctor or other medical professional placed you on a special diet?
*
Yes
No
Are you compliant with that diet?
*
Yes
No
Do you have any chronic chewing, swallowing or gastric problems that interfere with eating?
*
Yes*
No
Acknowledgement:
*
I acknowledge this Pain, Health and Nutrition Screening is completed to the best of my ability
Patient Signature:
*
clear
If patient is under 18, patent/guardian signature
clear
Parent/Guardian Name