Dr. Stuart Kordonowy
473
Hendersonville Rd., Suite A
Asheville, NC 28803
(828) 277-0903
E-mail: chirok@sprynet.com
Website: www.kordonowy.com
Confidential
Patient Information Date: ______________________
Name_______________________________________________________Social
Security____________________________________
Address_______________________________________City_________________Zip
Code__________________________________
Home
Ph._________________________ Cell Ph.________________________
E-mail____________________________________
Age__________Birth
Date________________________Martial
M S W D How many children? _____________________
Occupation____________________________________Employer______________________________________________________
Address_______________________________________Office
Ph.______________________________________________________
Name of
spouse________________________________Occupation_____________________________________________________
Employer_____________________________________
Address_______________________________________________________
Emergency
contact______________________________Relationship______________________Ph.___________________________
YOUR
CONDITION AND HEALTH HISTORY
How did you
hear about
us?_____________________________________________________________________________________
Is condition
due to injury or sickness arising out of patient’s employment? ___Yes ___No
Date symptoms
appeared or accident
occurred______________________________________________________________________
Has patient
ever had same or similar condition?
___Yes
___No If yes, describe
and give date of onset: _________
(Continue)___________________________________________________________________________________________________
Have you lost
any days from work due to this condition?
___Yes
___No
What
activities aggravate your
condition?__________________________________________________________________________
Is this
condition: ___ progressively
getting worse ___
constantly the same
___comes and goes
Is the
condition interfering with:
___work ___sleep ___daily routine ___other
How long has
it been since you really felt good?
____________________________________________________________________
Other doctors
seen for this condition? ____________________________________________________________________________
List
physicians, dentists, and alternative health care providers you have been
treated by in the last year:
Name
______________________________________ Condition treated _________________________________________________
Name
______________________________________ Condition treated
_________________________________________________
Name
______________________________________ Condition treated
_________________________________________________
May we send
information to the above mentioned healthcare providers in order to make them
aware of your progress and keep your
records
updated? ___Yes ___No Patient’s
initials___________________________________________________