Patient Demographic Information

You have an appointment on:

With:
Dr. Jules B. Bodo

At the following location:

619 Brighton Avenue, First Floor, Portland, ME 04102.
Office: Fax:
Parking is available on the premises on a first come first served basis

Name:

Date of Birth:

Address: Street:

City:

State:

Zip:

Home Phone

Work Phone

Cell Phone

SSN

Pharmacy Name

Pharmacy Location

Email Address(Optional)

Sex:

Male Female

Race: (Optional)

Caucasian

African American

Hispanic

Native American

Alaskan Native Asian

Ethnicity:

Hispanic/Latino Origin Non-Hispanic Origin Declined Primary

Language

Primary Care Physician

Date Last Seen:

REFERRAL SOURCE:

Primary Care Physician,

Family/Friend,

Internet,

Phone Book,

TV/Radio Ad,

Hospital Urgent care

Other Physician:

Athletic Trainer/School

Other

Other physician:

Athletic Trainer/School (Name)

Other (specify)

INSURANCE INFORMATION

Primary Insurance

ID#

Group#

Policy Holder Name

Date of Birth:

Secondary Insurance

ID#

Group#

Policy Holder Name

Date of Birth:

Employer Name

Employer Address

Past Medical History/Medical Problems/Illness Injuries.

Other (specify)

Surgical History (R-right L-left B-bilateral)

Anesthesia Complications Describe Previous Anesthesia Problem

Assistive Devices

Family History/Illness

I have NO family history (please proceed to next section)

Not Known/Adopted (please proceed to next section)

Social History

Marital/Legal Status:

Single Significant Other Widowed Married Separated Divorced

Occupation:

Partime Full time Retired Diabled

If Retired, Date:

Hand Dominance

Right Handed Left Handed Ambidextrous (Both)

Tobacco Use:

(Please indicate which best describes your habits)

Currently every day smoker (at least smoked 100 cigarettes in a lifetime and still smokes either regularly or periodically)

Current some day smoker (at least smoked 100 cigarettes and still smokes either regularly or periodically)

Former Smoker (has smoked at least 100 cigarettes in a lifetime but currently does not smoke)

Never Smoked (has not smoked 100 or more cigarettes in a lifetime)

Smoker (current status unknown but is known to have smoked at least 100 cigarettes in a lifetime)

Unknown if ever smoked

Alcohol Use: Drug Use: Exercise:

(Please indicate which best describes your habits)

How often do you consume alcohol:

Are you currently using any illicit drugs:

Have you had a history of illicit drug use:

How often do you exercise:

What exercise activities do you perform:

Review of Systems

(Please indicate if you currently are experiencing any of the following)

Psychiatric Ears/Nose/Throat/Mouth

Incontinence of Bowel

Anxiety

Impaired Hearing

Bowel Changes:

Depression

Dizziness

Sleep Pattern Disturbance

Nose Bleeds

Runny Nose

Genitourinary (GU) Endocrine

Frequent Sneezing

Cold Sores

Frequent Urination

Cold Intolerance

Snoring

Painful Urination

Heat Intolerance

Incontinence of Urine

Excessive Thirst

Cardiovascular

Blood in Urine

Weight Gain

Fainting

Excessive Urination

Chest Pain

Nighttime Urination

Weight Loss

Musculoskeletal

Leg Swelling

Skin Allergies

Change in Color

Hives

Mole Changes

Dryness

Frequent Infections

Rash

Environmental Allergies

Itchy Skin

Description of Current Problem/Illness

Location of Problem (please indicate by checking most accurate descriptions)

Lower leg

Right Left Bilateral

Ankle

Right Left Bilateral

Foot

Right Left Bilateral

1 st toe

2nd toe

3rd toe

4th toe

5th toe

Other:

Chief Complaint

Please describe your symptoms

Please describe your symptoms

Pain

Numbness

Tingling

Other

What is the date of injury?

Other (specify):

Please describe how this injury or complaint occurred:

Have you previously been treated for this injury/problem?

Yes No

If yes, when?

If yes, who treated you?

Primary Care Physician Specialist Hospital Urgent Care

If Specialist:

Pain Duration Pain Quality Pain Severity

Indicate Current Pain Level from 1-10

How long has this been a problem for you?

Started Today Since Last Night Started Yesterday For a While Unknown

Add new row

What Aggravates your pain:

Continuous Activity

Intermittent Bending

Occasional Moving

Worse at night

Worse with activity Standing

Home Exercise

Other (specify):

Previous Testing

Have you had any previous testing/studies done for this injury/problem?

Yes No

Add new row

Are You Currently Working?

No/Disabled Yes/Regular Duty No/Retired Yes/Light Duty No/Student

Medications/Drug Allergies:

Are you currently taking any medications?

Yes No

Add Medications/Drug Allergies

Are you allergic to any medications?

Yes No

Add Allergic

Please indicate if you have any of the following non-medication allergies:

Latex

Iodine

Tape/Band Aids

Contrast Dye

Other

Other (specify):

Your information will be encrypted.

Patient Demographic Information

With: Dr. Jules B. Bodo

INSURANCE INFORMATION

Past Medical History/Medical Problems/Illness Injuries.

Surgical History (R-right L-left B-bilateral)

Assistive Devices

Family History/Illness

Social History

Tobacco Use:

Alcohol Use: Drug Use: Exercise:

Review of Systems

Description of Current Problem/Illness

Chief Complaint

Pain Duration Pain Quality Pain Severity

Previous Testing

Are You Currently Working?

Medications/Drug Allergies:

Please indicate if you have any of the following non-medication allergies:

With:
Dr. Jules B. Bodo