RMOM Patient Form

Patient Information form

The information requested in this questionnaire is very important. To give you the best care and to obtain insurance approval if applicable, please fill out as completely as possible. When complete, click on the yellow SUBMIT button. This will send your health information in a secure manner to Rocky Mountain Osteopathic Medicine.

Your first name:     Last name:    Today's date:
Address:    Home Phone: Mobile Phone:
City: State:    Zip:
Email:     Date of Birth:    
In providing your mobile number and/or email address above, you grant Rocky Mountain Osteopathic Medicine the authorization to send you quarterly information regarding special announcements and offers.
Who referred you to our practice?
Who is your primary care doctor?

Primary Care First name:     Primary Care Last name:    
Address:    Phone Number:

Please tell us in one sentence if possible the primary reason for your desired visit:

Please provide us a date of injury or of symptom onset for your health issue:

Briefly describe how your injury occurred (if due to an injury):

Using a scale of 1-10 with 10 being the worst pain you have ever had and 0 being no pain at all, rate your current symptoms.
When my pain is the worst:
When my pain is the least:
Today my pain is:

Please check the word/words that best describe the nature of your symptoms/pain:
    Sharp            Shooting        Dull            Numbness     Burning     Tingling          Radiating

Check the activities that aggravate your symptoms:

  Sitting     Getting in/out of car     Reading  
  Standing     Driving car     Recreation  
  Walking     Reaching overhead     Work  
  Stair climbing     Reaching behind back     Athletics  
  Squatting     Putting on shirt     Coughing/Sneezing  
  Running     Buttoning shirt     Bending  
  Lifting     Putting on pants     Carrying >10 lbs  
  Putting on socks/shoes      
Please comment on any other activity that makes your pain worse:
Is there anything you can do to improve/decrease your pain:
How long can you stand with minimal or no pain?
How long can you sit with minimal or no pain?

Have any of the following diagnostic studies or testing been completed for your injury. Please indicate below.

Arthrogram           Myelogram          
MRI           Diskogram          
DEXA scan           EMG/nerve conduction        
Bone scan           Plain x-ray        
CT scan           Other        

PAST TRAUMATIC HISTORY (please include any motor vehicle accidents):

PREVIOUS WORK RELATED INJURIES (please indicate date and any loss time from work):

Please indicate any previous treatments you have had for your current problem.

    TREATMENTdetailsTREATMENT    details
Electrical Stimulation      Massage       
TENS unit      Pool exercises       
Ultrasound      Home exercises       
Hot packs      Manipulation DC/DO       
Cold packs      Acupuncture       
Whirlpool      Injections       
Physical Therapy      Biofeedback       
Please include any comments regarding the above treatments that you feel are important

PAST MEDICAL HISTORY (Please check each item that you have experienced or affects you.)

Diabetes   Allergies  
Chest pain angina   Heat or cold intolerance  
Hypertension   Hernia  
Heart disease   Seizures  
Heart palpitations   Metal implants  
Pacemaker   Dizziness fainting  
Headaches   Recent fractures  
Kidney problems   Skin abnormalities  
Currently pregnant   Sexual disfunction  
Cancer   Osteoporosis  
Bowel or bladder problems   Leakage of urine  
Asthma   Liver gallbladder problems  
Tobacco use   Stroke  

Please list any other medical problems not included above:

Are you currently taking any medications? If so, please indicate the name of the medication, dosage, and frequency below:

Please list any medications to which you may be allergic and please comment regarding the reaction you have experienced when taking it.

SURGICAL HISTORY (Please indicate all previous surgical interventions and dates.)

What do you do for a living? How long at this type of work?
Number of hours per week?  Other hobbies or sports interests?
Tobacco use?       Type?  Qty per day? How long?
Alcohol use?         Type?  Qty per day? How long?
Marijuana use?     Qty per day? How long?
Have you ever been treated for alcohol or drug addiction?  
Marital status?         Number of children
How many hours do you sleep at night? 
Please describe any difficulties you have with sleep.
FAMILY MEDICAL HISTORY (any significant past medical family problems that you are aware of?).

  FAMILY MEMBER  AgeLiving or deceasedIllnessesCause of death
Sibling 1                  
Sibling 2                  
Sibling 3                  

Please check each item that applies to you. We will discuss further at your visit.

What is your height?  Weight:
Have you had any weight loss or gain in the last year?      
If so, how much?
Skin/Breast         None
Rash   Itching   Pigmentation  
Dry skin   Changes in hair growth/hair loss   Nail changes  
Breast lumps   Breast tenderness   Breast swelling  
Nipple discharge    
Eyes/Ears/Nose/Mouth/Throat   None
Headaches   Dizziness   Lightheadedness   Double vision  
Tearing   Blind spots   Pain   Nose bleeding  
Colds   Obstruction   Discharge   
Dental Difficulties     None
Gum bleeding   Dentures   Neck stiffness   Neck pain  
Neck tenderness   Masses in your neck   Masses in other areas   
Cardiovascular         None
Chest pain   Chest or heart palpitations   Passing out spells  
Short of breath on exertion   Short of breath lying down   Swelling in your legs  
Hypertension   Heart murmurs   Varicose veins  
Phlebitis   Pain in your legs with walking   
Respiratory         None
Shortness of breath   Wheezing   Cough  
Respiratory Infections   Tuberculosis (or exposure to tuberculosis)   Fever or night sweats  
Gastrointestinal          None
Painful swallowing   Indigestion   Food intolerance  
Abdominal pain   Heartburn   Excessive gas  
Nausea   Vomiting   Bloody vomiting  
Yellow skin   Constipation   Diarrhea  
Abnormal stools   Dark or tarry stools   Bloody stools  
Hemorrhoids   Recent changes in bowel habits   
Genitourinary         None
Urgency   Frequency   Dysuria  
Frequent night-time urination   Bloody urine   Unusual (or change in) color of urine  
Stones   Infections   Hesitancy  
Change in size of stream   Dribbling   Acute retention  
Female         Not Applicable
Age of onset of menses:      First date of last period: 
Irregularity of menstrual cycle    
Painful, frequent, or excessive bleeding with your periods   Vaginal discharge  
Post-menopausal bleeding   Painful intercourse  
Musculoskeletal           None
Pain   Swelling   Redness or heat of muscles or joints  
Limitation of motion   Muscular weakness   Muscle cramps  
Neurologic/Psychiatric    None
Convulsions   Paralyses   Tremor  
Incoordination   Numbness or tingling in hands or legs   Difficulties with memory or speech  
Predominant mood "nervousness" (define)   Emotional problems   Anxiety  
Depression   Previous psychiatric care   Unusual perceptions  
Notes of explanation or clarification on any of the above: