NAME: _____________________________________________ DOB: __________________ AGE: ___________________
Referred by: _____________________________________ Primary Care: ________________________________________
Are you Right, Left Handed or Ambidextrous? (Please circle) Pharmacy Used:_____________________________________
Please describe what symptoms you are currently experiencing:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Was this related to any trauma or injury?  Yes  No
How Long has this been going on for? _______________________
CONSERVATIVE THERAPY:
Physical Therapy:
 Yes  No
Beneficial?:  Yes  No
Facility/Location: ___________________________
Pain Management:
 Yes  No
Beneficial?:  Yes  No
Facility/Location: ___________________________
Steroid Injections:
 Yes  No
Beneficial?:  Yes  No
Facility/Location: ___________________________
Chiropractic Treatment:  Yes  No
Beneficial?:  Yes  No
Facility/Location: ___________________________
Other Neurologists/Neurosurgeons Seen:_____________________________________________________________________
Do you see a Cardiologist, Oncologist, Hematologist or Pulmonologist?:______________________________________________
PAIN DESCRIPTION:
ALLEVIATING/AGGRAVATING FACTORS:
Numbness = NNN
Tingling = TTT
Please mark the above figure
with an “X” where your pain
is the worst right now.
Aching = AAA
Stabbing = SSS
Burning = BBB
Weakness = WWW
What makes your pain better?:
_______________________________
_______________________________
_______________________________
What makes your pain worse?:
_______________________________
_______________________________
_______________________________
On a scale of 1-10, what is the rating
of your average daily pain?: ________
What are some words that you can
use to describe your pain?
_______________________________
Please circle the appropriate number below showing how bad your
pain is now:
No pain 1 2 3 4 5 6 7 8 9 10 Worst possible pain
________________________________
REVIEW OF SYSTEMS (Check those that apply to your condition currently):
General:
 Unexplained fevers
 Weight loss
 Weight gain
 Excessive fatigue
 Appetite decrease
 Sleep disturbance
Musculoskeletal:
 Neck pain
 Joint pain/swelling
 Back pain
 History of fractures
 Muscle pain
 Muscle weakness
 Muscle cramps
Eyes:
 Visual disturbance
 Visual change
 Double vision
 Blurred vision
 Dry eyes
Women Only:
 Currently pregnant
 Mammogram in the last 2 years
 Currently in menopause
 Abnormal vaginal bleeding
 Vaginal discharge
 Perform monthly breast exams
 Taking birth control pills
 Pap smear in the last 2 years
Genitourinary:
 Urinary Incontinence
 Urinary Retention
 Urinary Frequency
 Painful Urination
Breast:
Ears:
 Hearing loss
 Dizziness
 Ringing
Nose:
 Nose bleeds
 Nasal obstruction/discharge
Mouth:
 Dry mouth
 Dentures/partial
Throat:
 Dry throat
 Sore throat
 Voice changes/hoarseness
 Difficulty swallowing
Cardiovascular:
 Rapid/Irregular heart beat
 Chest pain/pressure
 Lower extremity swelling
Respiratory:
 Wheezing
 Persistent or unusual cough
 Shortness of breath
 Sleep apnea
 Night sweats
 Breathing difficulty
 Lumps
 Nipple discharge
 History of breast cancer
Men Only:
 Erectile dysfunction
 Prostate cancer
Neurological:
 Disturbance of smell
Allergy & Immune Systems:
 Facial numbness/weakness
 History of shingles
 Disturbance of taste
 Food allergies
 Hearing difficulty/loss
 Immunizations up to date
 Speech difficulty
 Headaches
 Loss of consciousness
 Prior head injury/skull fracture
Other:
 Involuntary movement of limb(s)
 __________________________
 Seizure disorder
 __________________________
 Walking difficulty
 __________________________
 Numbness (Location: _______________________)
 Tingling (Location: _________________________)
 Pain going down arm(s)
 Pain going down leg(s)
 Weakness (Location: ________________________)
 Paralysis
Psychiatric:
 Mental health condition (List: _______________________)
 Depression
 Hallucinations
Endocrine:
 Intolerance to heat/cold
 Excessive thirst
 Abnormal skin color change
 Dryness of hair/skin
Gastrointestinal:
Blood & Lymph Systems:
 Abdominal pain
 Vomiting/nausea
 Bowel habit changes
 Blood in stools
 Bowel incontinence
 Constipation
 Diarrhea
 Swollen lymph nodes
 Abnormal bleeding
 Bleeding disorder
 Bruise easily
Past Health History:
Have you had any of the following diseases/medical conditions?
 AIDS/HIV
 Artificial Joints
 Cancer
 Depression
 Epilepsy
 Hepatitis
 Liver Disease
 Pneumonia
 Stroke
 Ulcers/Colitis
 Alcoholism
 Asthma
 Chemical Dependency
 Diabetes
 Heart Attack
 Abnormal Cholesterol (high or low)
 Migraine Headaches
 Peripheral Vascular Disease
 Suicide Attempts/Ideation
 Unusual Childhood Disease(s)
 Anemia
 Blood Pressure (high or low)
 Congenital Heart Defect
 Drug Abuse
 Heart Surgery
 Immune System Disorder
 Multiple Sclerosis
 Pulmonary Embolism
 Thyroid Problems
 Tropical Disease(s)
 Artificial Valves
 Bleeding Disorder
 COPD
 Emphysema
 Heart Disease
 Kidney Disease
 Pacemaker
 Polio
 Tuberculosis
 Sleep Apnea
Past Surgical History:
YEAR
PROCEDURE NAME
SURGEON
Have you ever had problems with anesthesia in the past?  Yes or  No (If yes, please describe):
________________________________________________________________________________________________________________________
Family Health History:
Relationship
Mother/Father’s Side
Health Condition/Disease
Alive or Deceased
Social History:
Marital Status: ____________________ Preferred Language: ________________________ Ethnicity/Race: ____________________
Number of Children: _______________ Hobbies & Recreational Activities:________________________________________________
Employer: ___________________________ Occupation: ___________________Highest Level of Education Completed: __________
Currently Disabled?:  Yes or  No If yes, since when?: _________ Currently Retired?:  Yes or  No If yes, since when?: _______
Smoking Status:
Drinking Status:
Recreational Drug Use:
Medical Marijuana Use:
 Yes or  No
 Yes or  No
 Yes or  No
 Yes or  No
Packs per day? _____________ # of years? ____________ Years Quit? ________________
Drinks per day? _____________ #of years? ____________ Years Quit?________________
Substance? _________________ # of years? __________ Years Quit?________________
How much per day? _______________ # of Years? __________ Years Quit? __________
Medication & Allergy History:
Please list your PRESCRIBED medications below.
Medication
Strength/Dose
How Often you Take
Prescribed By
Pharmacy Used
Do you take any blood thinners OR home oxygen?  Yes  No If yes, please list: ______________________________________________
Pain Medications Tried & Failed: _____________________________________________________________________________________
Muscle Relaxers Tried & Failed: ______________________________________________________________________________________
Please list your OVER THE COUNTER & SUPPLEMENTS that you take below.
Medication Name
Strength/Dose
How Often you Take
Please list your MEDICATION allergies below.
Medication Name
Allergic Reaction
Please list your NON-MEDICATION allergies below.
(Example: Iodine, Shellfish, Tape, Adhesive, Environmental, Food and Latex)
Allergen Name
Allergic Reaction
Please sign and date this form as being true and correct:
_____________________________________________
Patient Signature
_________________________________________
Date