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
    Low Back Mid Back Neck Other Better No Change Worse
    Occupational Therapy
    Low Back Mid Back Neck Other Better No Change Worse
    Chiropractic/Osteopathic
    Low Back Mid Back Neck Other Better No Change Worse
    Massage
    Low Back Mid Back Neck Other Better No Change Worse
    Brace
    Low Back Mid Back Neck Other Better No Change Worse
    Biofeedback
    Low Back Mid Back Neck Other Better No Change Worse
    Acupunture
    Low Back Mid Back Neck Other Better No Change Worse
    Herbs
    Low Back Mid Back Neck Other Better No Change Worse
    Injections:
                 
      - Trigger Point
    Low Back Mid Back Neck Other Better No Change Worse
      - Epidural/Facet
    Low Back Mid Back Neck Other Better No Change Worse
      - Nerve Root
    Low Back Mid Back Neck Other Better No Change Worse
    Regular X-Rays
    Low Back Mid Back Neck Other Patient Label Here
    MRI Scan
    Low Back Mid Back Neck Other
    Myelogram
    Low Back Mid Back Neck Other
    CT Scan
    Low Back Mid Back Neck Other
    Bone Scan
    Low Back Mid Back Neck Other
    EMG/NCV
    Low Back Mid Back Neck Other


    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.