Intake Questionnaire - Jane Barnwell, MD

Section 2:
Last name First name Email address
What tests have been done to evaluate your problem? PLEASE LIST ALL (Blood tests, X-rays, MRIs, CTs, EMGs, etc.)
When?	What test?	What was found?			What facility?







Who have you seen for this problem? PLEASE LIST ALL (Physicians, chiropractors, naturopaths, PT, message therapists, acupuncturists, etc.)
When?	Who?		Phone #	What was done?		Helped?

Section 3:

Last name First name Email address

List any surgeries you have had:

When

What

When

What

When

What

Do you have trouble sleeping? no yes: when did it start:

While sleeping, do you snore loudly gasp don’t know

Do you feel refreshed after sleep?

always usually rarely never

What keeps you from sleeping well? can’t stop thinking pain worry restless limbs

day/night rhythm out of whack other:

How long can you:

Sit in an office chair? Minutes

Stand? Minutes

Walk? minutes miles feet

Alcohol:

# drinks per

day month week year

Caffeine # / day:

Coffee Tea

Soda Chocolate

Tobacco # / day:

cigarettes packs cigars

cans of chew pipe bowls

Recreational drugs you are using: Marijuana Cocaine PCP Heroin Amphetamines Ecstasy None

Work, school, unemployment, disability or retirement.

Now

Since:

# hours / week

school unemp

disabled retired

Description:

Before

above

Since:

# hours / week

school unemp

disabled retired

Description:

Medical History: Check all active or recurring medical problems that have been diagnosed by a health care provider:

Head:

Headache

Migraine

Head injury

TMJ

Facial pain

Eyes:

Cataracts

Glaucoma

Heart/vascular:

High blood pressure

Heart attack

Congestive heart failure

Mitral valve prolapse

Blood clots

Atrial fibrillation

Lungs/breathing:

Asthma

Bronchitis

COPD

Emphysema

Sleep apnea

Tuberculosis

GI/abdominal:

Ulcers

GERDS

Hiatal hernia

Crohn’s disease

Gallbladder disease

Hepatitis A B C

Skin:

Eczema

Psoriasis

Kidneys/bladder:

Kidney stones

Kidney disease/failure

Bladder infections

Prostate hypertrophy

Endocrine:

Diabetes type 1

Diabetes type 2

Hyperthyroidism

Hypothyroidism

Rheumatologic:

Osteoarthritis

Rheumatoid arthritis

Gout

Osteoporosis/osteopenia

Fibromyalgia

Chronic fatigue synd.

Neurologic:

Stroke

TIA

Parkinson’s disease

Epilepsy

Neuropathy

Shingles

Postherpetic neuralgia

Cancer:

Skin

Lung

Breast

Prostate

Colorectal

Other cancer:

Psychiatric:

Depression

Anxiety

PTSD

Schizophrenia

Dementia

Bipolar disorder

Addiction:

Alcohol

Tobacco

Prescribed drugs

Recreational drugs

Immune diseases:

HIV / AIDS

Other:

Symptom Review: Check all current or recent symptoms:

Constitutional:

Unplanned weight loss

Unplanned weight gain

Recurrent fever

Night sweats

Skin:

Dry skin

Rashes

Itching

Changes in hair or nails

Blood/lymph systems:

Swollen/tender glands

Anemia

Easy bruising/bleeding, not on blood thinners

Eyes/ears/nose/mouth:

Vision loss

Double vision

Blurred vision

Hard of hearing

Earaches

Vertigo

Ringing in ears

Nosebleeds

Nasal discharge

Sinusitis

Dentures

Bleeding gums

Dry mouth

Trouble swallowing

Lungs:

Cough

Wheezing

Cardiovascular:

Swelling of feet

Chest pain

Cold hands/feet

Palpitations

Shortness of breath when walking

Varicose veins

Bladder:

Frequent urination

Painful urination

Loss of bladder control

Gastrointestinal:

Loss of appetite

Indigestion or nausea

Vomiting

Diarrhea

Constipation

Abdominal bloating/gas

Heartburn

Abdominal pain

Endocrine:

Excessive thirst

Heat intolerance

Cold intolerance

Musculoskeletal:

Muscle cramps

Stiff joints

Swelling of joints

Sexual:

Sexual problems

Sexual abuse as a child

Neurologic/Psychiatric:

Fainting

Dizzy spells

Tremors

Confusion

Concentration problems

Memory problems

Stress high med low

Family Medical History: Include your siblings (brothers and sisters)

Relation

Age if living

Age at death

Major problems

Cause of death

Father

Mother

What causes your stress?

What exercise do you do now?

How long ago did you last exercise? 0-3 days 4-7 days 1-3 weeks 4+ weeks

Answer the questions below using this scale: 0 = Never, 1 = Seldom, 2 = Sometimes, 3 = Often, 4 = Very Often

How often do you have mood swings?

0 1 2 3 4

How often do you smoke a cigarette within an hour after you wake up?

0 1 2 3 4

How often have you taken medication other than the way that it was prescribed?

0 1 2 3 4

How often have you used illegal drugs (for example, marijuana, cocaine, etc.) in the past five years?

0 1 2 3 4

How often, in your lifetime, have you had legal problems or been arrested?

0 1 2 3 4

Are you involved in a lawsuit? no yes: Describe:

Section 4:
Last name First name Email address
List any allergies and sensitivities you have
Allergen	What happens

List all the medications, vitamins and supplements you are currently taking.

Name of product		Dosage milligram / pill	Frequency times / day	Date started	What is it for?




















List all the medications, vitaminsand supplements you were taking but have stopped taking for pain, fatigue or related problems.
Name of product	Dosage milligram / pill		Frequency times / day	Date started	Date stopped	Why did you stop using it?

Intake Questionnaire Please fill in all blocks. The more complete the information, the more likely Dr. Barnwell will be able to help you.
Section 1:
Last name					First name			M.I.		Date
DOB	Left Right handed	Male Female		Referring provider			Primary care provider
*Federal laws prohibit us sending health information via normal email. Please create a password we can use to send info to you securely.
Phone number			Email address*			Create a password for secure email:*			Preferred contact method: Phone Secure email
Describe the reason for your visit:. Be as specific as you can.
What date did the problem start? Did it start Gradually Suddenly Not Sure
How did it start? Auto accident Work injury Other accident/injury After infection, illness or operation Not known Other:
Explain the cause of the problem:
On a scale from 0 to 10 indicate thePain level: 0 = No pain 10 = The worst pain imaginable (uncontrolled screaming) level you are feeling right now: Fatigue: 0 = Unlimited energy 10 = Completely exhausted (unable to lift your head) Ability to do daily activities: 0 = Fully functional 10 = Unable to function (unable to arise from your bed)
If you have pain, please answer the following questions:
Where is your worst pain? (Which pain you want to deal with first)
Does it travel or radiate anywhere else? No Yes: Where:
Does the pain intensity change during the day or from day to day? No Yes: Describe when it is the worst:
Is the pain Getting worse Getting Better Staying the same
What makes the pain better? Lying down Sitting Standing Walking Changing position Stretching Hot pack Cold pack Brace Distractions (Movies, TV, chatting, etc) Medications What helps the most?:
What makes the pain worse? Lying down Sitting Standing Walking Changing position Stretching Hot pack Cold pack Brace Work Stress Other:
Are there any other areas of pain? No Yes: Where:
Do you believe you must use opioids to control your pain? Yes No Are you willing to try other pain control methods? Yes No
What do you think will help you get better? Better understanding of the causes Exercise Yoga Meditation Biofeedback Stress management Physical Therapy Medication (pills) Surgery Other:

Section 4:

List any allergies and sensitivities you have

List all the medications, vitamins and supplements you are currently taking.

Dosage milligram / pill

Dosage milligram / pill