PATIENT QUESTIONNAIRE/HEALTH HISTORY

To ensure you receive a complete and thorough consultation, please provide us with important background information on the following form. If you do not understand the question, our receptionist will assist you.
Thank you.


HISTORY OF PRESENT CONDITION

Please note areas of pain.


3. Was the onset of this episode gradual or sudden?

4. Which of the following best describes how your symptoms occurred? (if your condition is post-surgical please indicate as per original injury)

5. Since onset, are your symptoms getting: (check one)

6. Have you had similar symptoms in the past?

More than one episode?

7. Nature of pain/symptoms (check all that apply)

8. As the day progresses, do your symptoms: (Check one)

9. Does the pain wake you at night?

10. Do you have pain/stiffness/numbness/tingling upon getting out of bed in the morning?

11. Since the onset of your current symptoms have you had:

14. Have you had any of the following tests?Indicate when and where:

Are you:


PATIENT QUESTIONNAIRE/HEALTH HISTORY

Past Medical History: (please check any conditions you have or have had in the past)


FAMILY HISTORY:

(Check those that apply)

Heart Disease/MI

High Blood Pressure

Stroke

Cancer

Diabetes

Asthma

Seizures

Bleeding Disorder

Thyroid Disease

Kidney Disease

Mental Illness

Acid Reflux/Ulcer

Unknown

Other

Are there any medical diseases conditions or problems that run in the family? Yes or No If yes, please tell us what they are and your relation to the person. (DO NOT WRITE NAMES)


SOCIAL AND PERSONAL HISTORY:

Do you smoke?

If you smoked and quit,

How long did you smoke?

Do you drink alcohol?

Are you:

Current living arrangement

List ALL SURGERIES you have had in the past with approximate dates indicating if the surgery was done on the left or right side if applicable.


Please list ALL CURRENT MEDICATIONS


Are you currently taking any of the following over the counter medications?


PATIENT QUESTIONNAIRE/HEALTH HISTORY

Review of Systems: Please review the following symptoms and check "Yes" or "No" based on your current or recent symptoms. Please list any other conditions that have not been included. Please follow up with your referring physician regarding any positives from the list below.

Constitutional

Fever

Chills

Loss of appetite

Night Sweats

Excessive weight gain

Excessive weight loss

Malaise

Excessive sleepiness

Unable to sleep

Other condition list

Neurological

Headache

Tremors

Numbness in the feet/legs

Numbness in the arms/hands

Weakness in the legs

Weakness in the arms

Trouble walking

Poor balance

Falls

Loss of consciousness

Seizures

Loss of memory

Confusion

Difficulty in speech

Trouble chewing

Trouble swallowing

Vertigo

Concussion

Other condition list

Cardiovascular

Chest pain

Palpitations

Shortness of breath at rest

Shortness of breath on lying flat

Leg swelling

Syncope/fainting spells

Heart murmurs

Heart failure

High blood pressure

Low blood pressure

Other condition list

Eyes

Double vision

Loss of vision

Decreased vision in the eyes

Glaucoma

Other condition list

Respiratory

Cough

Wheezing

Blood in sputum

Shortness of breath

Other condition list

Musculoskeletal

Back pain

Neck pain

Muscle weakness

Muscle pain (myalgia)

Fatigue

Muscle wasting

Muscular cramps

Joint pains

Joint swelling

Joint stiffness

Other condition list

Endocrine

Diabetes

Thyroid disease

Excessive thirst (polydipsia)

Heat intolerance

Cold intolerance

Sexual dysfunction

Other condition list

Ear/Nose/Throat

Ringing in the ears (tinnitus)

Dizziness

Vertigo

Loss of smell (anosmia)

Loss of taste (aguesia)

Hoarseness of voice

Decreased hearing/deafness

Sores in mouth

Other condition list

Hematological

Unusual bleeding

Sickle cell disease

Other condition list

Gastrointestinal

Loss of bowel control

Rectal bleeding

Jaundice

Gastric ulcer

Gastric bleeding

Hepatitis

Pancreatitis

Other condition list

Genitourinary

Loss of urine control

Urinary urgency

Blood in urine

Dark-colored urine

Kidney stones

Impotence

Sexually-transmitted disease

Other condition list

Skin

Rash

Itching (pruritus)

Photosensitivity

Tumors

Abnormal loss of hair

Pitting on the nails

Other condition list

Allergy

Frequent infections

Other condition list

Others:


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