Health History

Please read:

Thank you for choosing Athens Spine Center to provide you the best, most comprehensive pain management care. Please understand if this is your initial consult or you are a returning patient but it has been over a year, you will not receive an injection on your first appointment.
Patient Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Email
example@example.com
Sex assigned at birth?

MaleFemale
Please share your pronouns. Pronouns are the part of speech used to refer to someone in the third person.

He/Him/HisShe/Her/HersThey/Them/TheirsNo Preference
Health History

Patient Condition
Where is your pain located?
When did your symptoms appear?
Is this condition getting progressively worse?

YesNoUnknown
Rate the Severity of your pain on a scale where '1'=least pain and '10'=severe pain.
Numerical Value Only
Is your pain:

ConstantComes & Goes
Type of Pain

SharpDullThrobbingNumbnessAchingShootingBurningTinglingCrampsStiffnessSwelling
Activities or movements that are painful to perform

SittingStandingWalkingBendingLying Down
Have you been treated by another physician for this pain?

YesNo
If treated, please list the name of the treating provider:
Have you had a CT scan in the past 2 years?

YesNo
If yes, where?
Have you had an MRI in the past 2 years?

YesNo
If yes, where?
Have you had an XRAY in the past 2 years?

YesNo
If yes, where?
Have you had any other imaging in the past 2 years?

YesNo
If yes, please list the type of imaging and where:
If you have been treated in the Emergency Room or required hospitalization for pain related to your scheduled appointment, please explain below and include the name of the hospital that you visited:
Family History
AIDS/HIV

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Alcoholism

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Anorexia or Bulimia

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Arthritis

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Asthma

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Bronchitis

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Cataracts

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Chemical Dependency

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Chicken Pox

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Diabetes Type 1 - Insulin Dependent

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Diabetes Type 2 - Non-Insulin Dependent

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Emphysema

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Epilepsy

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Glaucoma

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Hepatitis

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Herpes

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
High Blood Pressure

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
High Cholesterol

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Kidney Disease

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Liver Disease

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Lupus

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Migraines

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Multiple Sclerosis

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Osteoporosis

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Parkinson's Disease

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Pneumonia

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Polio

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Prostate Problems

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Psychiatric Care

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Shingles

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Stroke or TIA

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Suicide Attempt

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Thyroid Problems

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Ulcers - Mouth

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Ulcers - Stomach

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Tumors, Growths

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Cancer

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Heart Disease

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Use Oxygen

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Sleep with a CPAP Machine

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Pacemaker/Defibrillator

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
Prosthesis

SelfMotherFatherDaughterSonBrotherSisterGrandmotherGrandfather
List any other Family History that may be pertinent:
Have you had a mammogram?

YesNoN/A
Date of mammogram:
Have you been diagnosed with Breast Cancer or had a bilateral mastectomy?

YesNo
Have you had a colonoscopy in the last 10 years?

YesNo
Date of colonoscopy:
Have you had a total colectomy or colorectal cancer?

YesNo
Vaccine History
Have you received the COVID-19 Vaccine?

YesNo
If so, when?
Date
Have you received the Flu Vaccine?

YesNo
If so, when?
Date
Have you received the Shingles Vaccine?

YesNo
If so, when?
Date
Have you received the Pneumonia Vaccine?

YesNo
If so, when?
Date
Please list any other vaccines that you have previously had (include date received)
Injuries/Surgeries
Back or Neck Surgeries - Please provide the date of surgery, where, and physician
Other Surgeries - Please provide the date of surgery, where, and physician
Falls - Please list any falls and the date that they occurred
Head Injuries - Please list all head injuries and the date that they occurred
Broken Bones - Please list all broken bones and the date that they occurred
Habits
Smoking?*

YesNo
If yes, how many packs per day
Alcohol?*

YesNo
If yes, how many drinks per week
Drugs/Street Drugs?*

YesNo
If yes, how often and what drugs
High Level Stress?*

YesNo
Reason:
Should be Empty:

Please read:

Health History

Family History

Vaccine History

Injuries/Surgeries

Habits