Patient Personal Info

Personal Health History

Please mark on the line below to describe the level of pain/discomfort you are having today:
012345678910
No Pain
Worst Pain Ever
 

Your pain feels:
DullAchyBurningStabbingNumbnessTinglingPullingCrampingTightnessOther

Which of the following which have you had for your low back/mid-back/neck? Did the treatment make you:
Low Back
Mid-Back
Neck
Other
Better
No Change
Worse
Physical Therapy
Occupational Therapy
Chiropractic/Osteopathic
Massage
Brace
Biofeedback
Acupunture
Herbs
Injections:
             
  - Trigger Point
  - Epidural/Facet
  - Nerve Root
Regular X-Rays
Patient Label Here
MRI Scan
Myelogram
CT Scan
Bone Scan
EMG/NCV


Check all of those apply to you:
Bowel Function:
Bladder Function:
Leg /Foot:
Arm /Hand:

It is normal for patients faced with daily pain to experience emotional reactions such as worry, frustation and sadness. Please select the appropriate number to indicate the extent that you are troubled by the following:
None
Severe
Anxiety
012345678910
Depression
012345678910
Irritability
012345678910
YesNo   Was this problem for you prior to having the pain for which you seeing us today?
YesNo   If so, is it worse since developing this pain?
YesNo   Do you currently take medication for anxiety or depression?
YesNo   Have you received counseling for anxiety or depression?
YesNo   Do you have a history of psychological disease? (ie: ADD, Obsessive Compulsive Disorder, Bipolar, Schizophrenia)
Please specify:   

Prior Medical History

List ALL allergies to medications:

Medication
Reaction
Medication
Reaction

List ALL (prescription and non-prescription) you currently take:

Medication Name
Dosage
Medication Name
Dosage
List all medications previously taken for your pain:   
Gastrointestinal:
Do you have ulcers? YesNo
Has your ulcer bled? YesNo
Do you have reflux, hiatal hernia or GERD? YesNo

Alcohol / Drugs:
What is your approximate weekly use of alcoholic beverages?
I don't drink alcohol
Less than 1-2 drinks a week
3-6 drinks a week
Drink some alcohol on a daily basis

Have you or a parent ever had a problem with:
Alcoholism YouParentNo
Drug Abuse YesParentNo

Tobacco:
What is your approximate daily use of tobacco?
I don't smoke1 pack per dayMore than 2 packs per day1/2 pack per day1-2 packs per day

OB/GYN: (Women Only)
Date of last menstruation:  NormalAbnormalHysterectomy/Postmenopausal/Premenopausal
Date of last pelvic exam:  NormalAbnormal
Date of last PAP Smear:  NormalAbnormal
Pregnant or possibly pregnant:  YesNo
Breast Feeding:  YesNo

Current Medical Problems: (Please list)

Prior Surgeries: (Please list)

Type
Date
Type
Date

Family History:

Living (Yes/No)
Current health issues or cause of death
*Father
YesNo
*Mother
YesNo
*Spouse
YesNo
Brothers
Living
Deceased
Sisters
Living
Deceased
Children
Living
Deceased

Reviews of systems:

Check next to any of the symptoms you have had during the past year:

Work:

Date last worked:
Work status at the time of
Injury Onset
Currently
On disability
Regular: full time
Regular: part time
Permanent light duty
Temporary light duty
Temporarily Disbled (Not working)
Retired

How physically demanding is your job?

How satisfied are you with job?

Social:

What are some of your usual recreational activities that you had participated in the YEAR BEFORE your current problem?
Please checkbox in front of those you currently cannot perform.

Education:

Did not finish High SchoolHigh SchoolCollegePost Graduate

Attorney:

Does an attorney assist you with your injury claim?
YesNo   

Primary Care Physician:

Please inform me as any portion of the physical examination that I will perform causes you pain. Please do not perform any motion that causes your symptoms to worsen. An initial evaluation will occasionally increase your symptoms since painful structures are being evaluated.

Please sign and date this form.