PATIENT QUESTIONNAIRE/HEALTH HISTORY

Name

Date

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

1. What are your symptoms?

Please note areas of pain.

2. When did your symptoms begin? (Please indicate a specific date if possible)

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

Gradual

Sudden

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

Lifting

A MVA (car accident)

A Fall

Overuse

Trauma

Degenerative process

During recreation sports

Throwing

Incident at work

Unknown

Other

Which?

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

Better

Worse

Not changing

6. Have you had similar symptoms in the past?

Yes

More than one episode?

Yes

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

Sharp

Dull

Throbbing

Aching

Occasional

Constant

Other

Which?

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

Increase

Decrease

Stay the same

9. Does the pain wake you at night?

Yes

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

Yes

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

Any difficulty with control of bowel or bladder function

Numbness

Any dizziness or fainting attacks

Weakness

Unexplained weight change

Night pain / sweats

Malaise (vague feeling of bodily discomfort)

12 What aggravates your symptoms?

13. What relieves your symptoms?

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

None

Nerve conduction/EMG

X-rays

CT Scan

MRI Scan

Arthrogram

Myelogram

Bone Scan

Epidural Steroid Injection

Selective Nerve Block

Trigger point injections

Chiropractic Manipulations

Sympethectomy

Rhizotomy

Other

Which?

Where was the test performed and when

Are you:

Left handed

Right handed

Current weight

Current height

PATIENT QUESTIONNAIRE/HEALTH HISTORY

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

High Blood Pressure

Low Blood Pressure

Diabetes- years?

Asthma

Shortness of Breath

Emphysema

Chronic Cough

Tuberculosis

Coronary Artery Disease

Paralysis

Herniated Disc in Neck / Back

Peripheral Neuropathy

Angina

Cardiac Arrhythmia/A-Fib

Heart Attack

Congestive Heart Failure

Mitral Valve Prolapse

Blood Clots

Anemia

Bleeding Problems

Stroke

Spinal Fracture

Spinal Stenosis

Peripheral Vascular Disease

Seizures

Multiple Sclerosis

Parkinson's Disease

Thyroid Disease

Kidney Disease

Liver Disease

Hepatitis A, B, or C

Irritable Bowel Syndrome

Gastritis/Peptic Ulcer Disease

Back Pain/ Back Injury

Neck Pain/Neck Injury

Cancer-Type

GI Bleeding

Constipation

Enlarged Prostate/Urinary Retentione

Endometriosis

HIV

Osteopenia/Osteoporosis

Arthritis (Hip, Knee, Shoulder)

Fibromyalgia

Head Injury

Numbness in Hands

Numbness in Feet

Other

FAMILY HISTORY:

(Check those that apply)

Heart Disease/MI

Mom

Dad

Sibling

High Blood Pressure

Mom

Dad

Sibling

Stroke

Mom

Dad

Sibling

Cancer

Type

Mom

Dad

Sibling

Diabetes

Mom

Dad

Sibling

Asthma

Mom

Dad

Sibling

Seizures

Mom

Dad

Sibling

Bleeding Disorder

Mom

Dad

Sibling

Thyroid Disease

Mom

Dad

Sibling

Kidney Disease

Mom

Dad

Sibling

Mental Illness

Mom

Dad

Sibling

Acid Reflux/Ulcer

Mom

Dad

Sibling

Unknown

Mom

Dad

Sibling

Other

Mom

Dad

Sibling

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?

Yes

Packs per day

Years:

If you smoked and quit,

Date:

How long did you smoke?

Years:

Do you drink alcohol?

Yes

Drinks per week

If you drank and quit when did you quit?

Have you ever had a problem with drugs or alcohol?

Are you:

Single

Married

Divorced

Separated

Widowed

Current living arrangement

Live alone

Spouse

Roommate

Parents

Significant other

Level of Education

Where do you work and in what status? (If retired, list most recent place of employment and date of retirement)

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

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

MEDICATION

Dosage

Frequency

Route of Admin

(If needed please ask for an additional list)

ALLERGIES

DRUG ALLERGIES

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

Aspirin

Tylenol

Steroids

Antihistamines

Vitamins

Advil

Coumadin

Other

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

Yes

Chills

Yes

Loss of appetite

Yes

Night Sweats

Yes

Excessive weight gain

Yes

Excessive weight loss

Yes

Malaise

Yes

Excessive sleepiness

Yes

Unable to sleep

Yes

Other condition list

Neurological

Headache

Yes

Tremors

Yes

Numbness in the feet/legs

Yes

Numbness in the arms/hands

Yes

Weakness in the legs

Yes

Weakness in the arms

Yes

Trouble walking

Yes

Poor balance

Yes

Falls

Yes

Loss of consciousness

Yes

Seizures

Yes

Loss of memory

Yes

Confusion

Yes

Difficulty in speech

Yes

Trouble chewing

Yes

Trouble swallowing

Yes

Vertigo

Yes

Concussion

Yes

Other condition list

Cardiovascular

Chest pain

Yes

Palpitations

Yes

Shortness of breath at rest

Yes

Shortness of breath on lying flat

Yes

Leg swelling

Yes

Syncope/fainting spells

Yes

Heart murmurs

Yes

Heart failure

Yes

High blood pressure

Yes

Low blood pressure

Yes

Other condition list

Eyes

Double vision

Yes

Loss of vision

Yes

Decreased vision in the eyes

Yes

Glaucoma

Yes

Other condition list

Respiratory

Cough

Yes

Wheezing

Yes

Blood in sputum

Yes

Shortness of breath

Yes

Other condition list

Musculoskeletal

Back pain

Yes

Neck pain

Yes

Muscle weakness

Yes

Muscle pain (myalgia)

Yes

Fatigue

Yes

Muscle wasting

Yes

Muscular cramps

Yes

Joint pains

Yes

Joint swelling

Yes

Joint stiffness

Yes

Other condition list

Endocrine

Diabetes

Yes

Thyroid disease

Yes

Excessive thirst (polydipsia)

Yes

Heat intolerance

Yes

Cold intolerance

Yes

Sexual dysfunction

Yes

Other condition list

Ear/Nose/Throat

Ringing in the ears (tinnitus)

Yes

Dizziness

Yes

Vertigo

Yes

Loss of smell (anosmia)

Yes

Loss of taste (aguesia)

Yes

Hoarseness of voice

Yes

Decreased hearing/deafness

Yes

Sores in mouth

Yes

Other condition list

Hematological

Unusual bleeding

Yes

Sickle cell disease

Yes

Other condition list

Gastrointestinal

Loss of bowel control

Yes

Rectal bleeding

Yes

Jaundice

Yes

Gastric ulcer

Yes

Gastric bleeding

Yes

Hepatitis

Yes

Pancreatitis

Yes

Other condition list

Genitourinary

Loss of urine control

Yes

Urinary urgency

Yes

Blood in urine

Yes

Dark-colored urine

Yes

Kidney stones

Yes

Impotence

Yes

Sexually-transmitted disease

Yes

Other condition list

Skin

Rash

Yes

Itching (pruritus)

Yes

Photosensitivity

Yes

Tumors

Yes

Abnormal loss of hair

Yes

Pitting on the nails

Yes

Other condition list

Allergy

Frequent infections

Yes

Other condition list

Others:

E-Signature

Please sign electronically below.

Submit Signature Clear Signature

Click submit and you hereby give consent to sign this document electronically.

Sending data