***PLEASE PRINT NAME AND DATE OF BIRTH ON THE TOP OF EACH FOLLOWING PAGE***
Patient Name: ________________________ _______________________________
(First)
(Last)
Social Security Number: _____________________ Date of Birth: ________________________
(mm/dd/yyyy)
Gender:
Marital Status:
Male
Female
Unmarried
Married
Single
Ethnicity:
Race:
Hispanic or Latino
Widowed
Not Hispanic or Latino
Divorced
American Indian or Alaska Native
Language:
Asian
English
Other ________________
Black or African American
Native Hawaiian or Other Pacific
Other Race
Hand Dominance (choose one):
White
Ambidextrous
Left Hand Dominant
Right Hand Dominant
Communication Preference (choose one):
Phone
Cell Phone
Address: ___________________________________
Phone: _______________________
___________________________________
Cell: _________________________
City: ____________________ State: __________
Work Phone: __________________
Zip: ____________________
Patient Employer: ________________________________________
Advanced Directive (Living Will): Do you have an Advanced Directive?
Check yes only if you can provide us a copy today.
Yes /
No
Emergency Contact
Name: ____________________________________
Home Phone: ___________________
Relationship:_______________________________
Cell Phone: __________________
Pharmacy: ________________________________________________
Pharmacy Phone: __________________________________________
Patient Name:
DOB:
Referring Doctor: __________________________________________
Primary Care Physician: _____________________________________
Patient’s Primary Insurance Plan: __________________________________________________
Is your insurance a benefit provided directly to you or through a spouse, parent, or other person?
Self
Spouse
Parent
Other
Please list Name if other than self: _______________________________________
Please list Birth Date if other than self: ____________________________________
(mm/dd/yyyy)
Please list Social Security Number if other than self: _________________________
Please list Address if other than self:
Address: __________________________________________________________________
City: ____________________ State: __________
Zip: ____________________
Please list Phone if other than self: _____________________________
CHIEF COMPLAINT: (Give a brief description of the nature of your visit – for example, left knee pain)
_____________________________________________________________________________________
_____________________________________________________________________________________
Please describe how your injury occurred: __________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever had this problem in the past? No
Yes
Were you seen in the Emergency Room for your complaint?
No
Yes , Date: ________________
Were x-rays taken?
No
Yes
Were medications prescribed? No
Yes
Name of medications: __________________________________________
Did another physician treat you for your complaint?
No
Yes , Physician: ____________________________ Date: ________________
Have you seen a Pain Management physician?
No
Yes
Have you had prior diagnostic studies for your complaint?
No
Yes , CAT Scan / X-Ray / Bone Scan /
MRI /
EMG
Where? _____________________________
Date: ________________
Patient Name:
DOB:
REVIEW OF SYSTEMS
****PLEASE ONLY MARK YES TO PROBLEMS YOU ARE CURRENTLY HAVING****
Heat Intolerance
Hot Flashes
Other:
EYES
Blurred Vision
Eye Pain
Failing Vision
Vision Loss
Other:
GASTROINTESTINAL
Abdominal
Appetite Loss
Blood in Stool
Diarrhea
Constipation
GI Bleed
Heartburn
Nausea
Vomiting
Other:
GENITOURINARY
Difficult Urination
Excess Urination
CARDIOVASCULAR
Bleeding Problems
Chest Pain
Circulation Problems
Palpitations
Other:
CONSTITUTIONAL
Fatigue/Weakness
Itching
Skin Problems
Weight Gain
Weight Loss
Other:
E.N.T.
Ear Discharge
Hearing Loss
Nosebleeds
Runny Nose
Sore Throat
Other:
ENDOCRINE
Cold Intolerance
Fatigue
Frequent Urination
(PM)
Leakage of Urine
Painful Urination
Passing Stones
Pregnancy
Retention of Urine
Other:
MUSCULOSKELETAL
Ankle Swelling
Disturbance in Walking
Extremity Numbness
Extremity Pain
Extremity Weakness
Joint Pain
Joint Swelling
Low Back Pain
Mid Back Pain
Muscle Cramps
Muscle Weakness
Neck Pain
Numbness
Stiffness
Tingling Sensation
Other:
NEUROLOGICAL
Difficulty Walking
Dizzy Spells
Memory Loss
Severe Headaches
Weakness
Other:
PSYCHIATRIC
Anxious
Depressive state
Memory Loss
Other:
RESPIRATORY
Chest Pain
Chronic Coughing
Difficulty Breathing
Shortness of Breath
Other:
ALLERGIES TO MEDICATIONS/FOODS
Name of Medication/Food
Reaction
NONE
1._______________________
Chest pain Breathing Difficulties Headaches Hives Itching
Throat tightness Muscle/Joint Pain Other ____________
Nausea
2._______________________
Chest pain Breathing Difficulties Headaches Hives Itching
Throat tightness Muscle/Joint Pain Other ____________
Nausea
3._______________________
Chest pain Breathing Difficulties Headaches Hives Itching
Throat tightness Muscle/Joint Pain Other ____________
Nausea
4._________________________
Chest pain Breathing Difficulties Headaches Hives Itching
Throat tightness Muscle/Joint Pain Other ____________
Nausea
5._________________________
Chest pain Breathing Difficulties Headaches Hives Itching
Throat tightness Muscle/Joint Pain Other ____________
Nausea
6._________________________
Chest pain Breathing Difficulties Headaches Hives Itching
Throat tightness Muscle/Joint Pain Other ____________
Nausea
7._________________________
Chest pain Breathing Difficulties Headaches Hives Itching
Throat tightness Muscle/Joint Pain Other ____________
Nausea
Patient Name:
DOB:
FAMILY MEDICAL HISTORY
(Check problem and indicate who was diagnosed: Mother= M, Father = F, Sibling = S, Grandparent = G)
Adopted
Disorder
Who
Alcohol Liver Disease………………
Bleeding Disorder…………………...
Mental Disorder……………………..
Diabetes…….. 1…… 2……………...
GERD……………………………….
Heart Disease……………………….
Stroke……………………………….
Anesthetic Complications…………...
Rheumatoid Arthritis………………..
Osteoarthritis ………………………..
Cancer
Type: __________________
Type: __________________
Type: __________________
Type: __________________
Type: __________________
M
M
M
M
M
M
M
M
M
M
M
F
F
F
F
F
F
F
F
F
F
F
S
S
S
S
S
S
S
S
S
S
S
G
G
G
G
G
G
G
G
G
G
G
M
M
M
M
M
F
F
F
F
F
S
S
S
S
S
G
G
G
G
G
PAST SURGICAL HISTORY (Please print)
NO PAST OPERATIONS
General Surgery
AAA Repair (year:
AICD (year:
)
Appendectomy (year:
Breast Surgery (year:
CABG (year:
)
Caesarean Section (year:
Carotid Endarterectomy (year:
Cataract Extraction (year:
Cholecystectomy (year:
Colon Resection (year:
Defibrillator Implant (year:
Fundoplication (year:
)
)
)
)
)
)
)
)
)
Gall Bladder (year:
Gastric Bypass (year:
Heart Procedure/Surgery (year:
Hernia (year:
Hysterectomy (year:
Lung Surgery (year:
Pacemaker (year:
Prostate Surgery (year:
Tonsillectomy (year:
Tubal Ligation (year:
Other:
)
)
)
)
)
)
)
)
)
)
)
Orthopedic Surgery
Arthroscopy (year:
Ankle
Lt / Rt (year:
Elbow
Lt / Rt (year:
(year:
Fingers Lt / Rt (year:
Hip
Lt / Rt (year:
Knee
Lt / Rt (year:
Shoulder Lt / Rt (year:
Wrist
Lt / Rt (year:
)
)
)
)
)
)
)
)
)
Ankle Replacement
Lt / Rt (year:
)
Carpal Tunnel Release Lt / Rt (year:
)
Hip Replacement
Lt / Rt (year:
)
Knee Replacement
Lt / Rt (year:
)
Shoulder Replace.
Lt / Rt (year:
)
Back Surgery
Cervical Thoracic Lumbar
(year:
)
Implants/Hardware (pins, rods, screws, plate): which body
part: _____________________________
Patient Name:
DOB:
PAST MEDICAL HISTORY
Abdominal Problems:









Gastritis
Gallstones
Hernia
GERD/Acid reflux/Heartburn
Diverticulosis
Colitis











Congenital Disease
-high blood pressure
Coronary Artery Disease
Arrhythmia
Pacemaker / Defibrillator
Murmur
CHF / Congestive Heart
Failure
Obesity
Sickle Cell Anemia
Anemia
Chemo







Bone / Joint


Stones
MRSA / Staph.
HIV – AIDS
Herpes
TB (Tuberculosis)
Lyme Disease
Surgery
Problems:
Blood Clots/DVT
Peripheral Artery Disease
Varicose Veins
Stroke/ TIA
Phlebitis
Aneurysm
Meniere Disease
Deviated Septum
Sinus infections
_________________
Cataracts
Dialysis


Currently Pregnant

Renal Transplant





Jaundice
Cirrhosis
Fractures: (describe)
________________________


Laceration:______________
Coccydynia (Tailbone Pain)
Neuropathy
MS (Multiple Sclerosis)
Alzheimer’s
Parkinson’s
Seizures
Myasthenia Gravis
Headaches
Upper Extremity Diagnosis:
Tear





Asthma
COPD
Emphysema
Sleep Apnea:
TB exposure
Macular Degeneration


________________________

Lower Extremity Diagnosis
________________________





Osteoarthritis








Depression




Acne
Rheumatoid Arthritis
Degenerative Joint Disease
Polymyalgia
Fibromyalgia
/ Osteopenia
Liver Transplant
Poor / Failing Vision
Cardiologist:
DR.____________________

Herniated Disc
Vertigo
Orthopedic / Arthritis /
Rheumatology:
Failure
Glaucoma
Blindness
Scoliosis
Reproductive:
TMJ Problems
Thyroid High Low











Rheumatic Fever
Radiation
Ear / Nose / Throat Problems:
 Deafness / Hearing Problems







Colostomy / Ileostomy
Polycythemia
: (describe)
_______________________________



MI / Heart Attack
Irritable Bowel Synd.
Blood Bourne Pathogen Exposure









Degenerative Disc Disease
Spinal stenosis
Anxiety
Bi-Polar
ADD / ADHD
Panic Attacks
Claustrophobia
Schizophrenia
PTSD
Psoriasis
Rosacea
Vitiligo
Patient Name:
DOB:
SOCIAL HISTORY
Do you smoke?
Yes
Quit
If the answer is YES or QUIT,
When did you quit?
Maximum number of packs per day?
Total number of years?
Do you chew tobacco?
Yes
If the answer is YES or QUIT,
When did you quit?
Maximum amount per day?
Total number of years?
Marital status:
Single
___________
___________
___________
Quit
Never
___________
___________
___________
Do you drink alcohol (including beer or wine)? No
Are you a recovering alcoholic?
Never
No
Yes
, Number of drinks per week? _____
Type of alcohol? ______________
Yes
Married
Widowed
Divorced
OCCUPATION: Working title: __________________________ Are you retired? No
Yes
If retired,
please list pre-retirement occupation: ______________________________________
Name of employer: _____________________________________
Job position: ________________________________________ Full Time: No
Yes
/ Part Time: No
Length of time in this position: ____________ Length of time at this company: ____________
Is this complaint related to a:
Workers’ Compensation claim?
No
Yes, DATE OF INJURY: _________________
Motor Vehicle Accident?
No
Yes, LAST DATE WORKED: _____________
Personal Injury?
No
Yes
Is there an attorney involved?
No
Not yet
Yes
Name of attorney: ______________________________________________________________
Yes
Patient Name:
DOB:
CURRENT MEDICATIONS (Including over-the-counter medications)
(Please print)
NOT CURRENTLY TAKING ANY MEDICATIONS
Name of Drug:
1. ___________________________
2. ___________________________
3. ___________________________
4. ___________________________
5. ___________________________
6. ___________________________
7. ___________________________
8. ___________________________
9. ___________________________
10. ___________________________
11. ___________________________
12. ___________________________
13. ___________________________
14. ___________________________
15. ___________________________
16. ___________________________
17. ___________________________
18. ___________________________
19. ___________________________
20. ___________________________
Dosage:
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Frequency: How Long have you
taken this medication?
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
This medication
has helped:
A lot
Some None
Patient Name:
DOB:
Using the diagram below, mark your area(s) of pain:
RIGHT
LEFT
LEFT
RIGHT
FRONT
BACK
DESCRIBE YOUR PAIN:
Severity: Mild Moderate Severe
Quality:
Dull Sharp Aching Throbbing
Duration: Intermittent Constant
Night
Day
Made better by: _______________________________________________________
Made worse by: _______________________________________________________
DAILY ACTIVITIES
Activity
Able
Not Able
Explanation
Dressing Self
Personal Hygiene
Household Cleaning
Grocery Shopping
Read
Manage Own Money
Laundry
Eating
Cooking
Driving
Watching Television
Use Computer
Part-Time Work
I HAVE:
I HAVE HAD THIS PROBLEM FOR:
Neck Pain Only
________ Days
Neck Pain and Arm Pain
________ Weeks
Upper Back Pain (Thoracic)
________ Months
Low Back Pain Only
________ Years
Low Back and Leg Pain
Scoliosis