Patient History

1. Patient History (Fill out on the internet and send) OR
2. Patient History (Download, print, fill-out and bring with you) CLICK HERE

First Name:

Last Name:
Date:
Phone: Home
Work:
Cell:
Referred by:
Primary MD:
Occupation:

Pain History:

Where is your pain? (Specificaly):
Does it radiate anywhere?
When did it begin?
How did it begin?
Was there an accident, injury or event which caused it?
Has your pain changed recently?
Do you have a pending lawsuit? 
-Yes -No

Pain description: How would you describe your pain?  (check as many as apply)

-Sharp 
-Aching
-Hot/burning
-Electrical
-Fearful
-Throbbing
-Cramping
-Crushing
-Splitting
-Punishing/Cruel
-Shooting
-Stabbing
-Heavy
-Tender

Intensity: on a scale from 0 to 10 ( 0 = no pain, 10 = worst imaginable pain)

Rate your pain:
Today:
At its worst:
At its best:
On Average:

What makes your pain better?

-Resting
-Sitting
-Standing
-Walking
-Heat
-Ice
-Medication
-Other

What makes your pain worse?

-Sitting
-Standing
-Walking
-Bending
-Arching
-Twisting
-Lifting
-Other

What medications do you take for pain?

List all with doses?
What physician perscribes your pain medication?
Do you have numbness? 
-Yes -No --- -If yes Where?
Do you have weakness? 
-Yes -No --- - If yes Where?
Have you had a recent problem with bowel or bladder function?      
-Yes -No

Previous Treatments:

Who has treated your pain so far?

What treatments have been tried so far: (please check as many as apply)

-Physical Therapy: 
-Surgery:
-Chiropractic:
-TENS:
-Pain Blocks:
-Behavioral:
-Psychiatric:  
-Other

Testing: (If yes please fill in when test was completed)

MRI:  
CT Scan: Myelogram: Bone Scan: 
EMG: Discogram: Other:  

Medical History:
Please list all medication allergies and the reaction you had to the medications:

Medications:

What medications do you take generally?

List all with doses?

Blood Thinners:

-Coumadin 
-Plavix 
-Lovenox 
-Heparin
 -Aspirin -Aggrenox

Past surgeries and hospitalizations: (list)

Past Medical History:

-Peripheral Vascular Disease
-Heart Disease
-Diabetes
-Kidney Disease
-Stroke
-Hypertension
-Cancer
-Arthritis
-Psychiatric/Emotional -Lung Disease -Stomach Disorders -Bowel Disease
-Other -Seizures -Infections/Sepsis -Pregnancy