Lumbar Patient History Form
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email
example@example.com
Marital Status
*
Married
Single
Divorced
Widowed/Widower
Other
Sex
*
Please Select
Male
Female
Occupation
Employer
Employer Phone Number
Please enter a valid phone number.
Race
*
Please Select
American Indian
Black/African American
Native Hawaiian
White
Asian
Other
Ethnicity
*
Please Select
Hispanic/Latino
Not Hispanic/Latino
Language
*
Please Select
English
French
German
Japanese
Mandarin
Russian
Spanish
Other
Referring Physician
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Primary Care Physician
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Contact
Relationship
Phone Number
Please enter a valid phone number.
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Next
Primary Insurance Information
Primary Insurance
*
Insurance Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Phone Number
*
Please enter a valid phone number.
ID #
*
Group #
*
Secondary Insurance
If you have secondary insurance, please provide your details here.
Secondary Insurance Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
ID #
Group #
Name of Insured
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
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Injury Information
Is your condition due to a workplace injury or motor vehicle accident?
*
Yes
No
Date of Injury
-
Month
-
Day
Year
Date
Claim #
Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Back
Next
Patient History (Lumbar Spine)
Reason for visit:
Back Pain
Leg Pain
Other
What symptoms are you experiencing:
Pain
Numbness
Tingling
Weakness
Dull
Aching
Shooting
% Back Pain
What percent of your pain is back pain?
% Leg Pain
What percent of your pain is leg pain?
Describe your symptoms:
What part of your leg does your pain radiate into?
Right
Left
Both Right and Left
Upper
Lower
Both Upper and Lower
How long have you had your symptoms?
Days
Weeks
Months
Years
Describe how and when symptoms started:
What kind of treatment have you had:
MRI
XRays
CT
Pain Management
Have you had physical therapy?
Yes
No
Have you had chiropractic treatment?
Yes
No
Have you had home exercise treatment
Yes
No
Have you had any injections?
Yes
No
Did you benefit from any of these treatments/modalities?
Yes
No
List over the counter and prescribed medications you have taken for your symptoms:
In the last 6 months has your pain:
Improved
Stayed the same
Gotten Worse
How often are you in pain?
Occasionally
Intermittent
Frequent
Constant
Activities that make pain worse:
Sitting
Standing
Walking
Bending forward
Bending backward
Lying down
Other
Activities that help your symptoms:
Sitting
Standing
Walking
Lying down
Changing position
Medication
Ice
Heat
Rest
Other
What specific activity limitations have you had since your injury?
Please list all you can think of related to driving, working, daily living conditions, etc.
Drug Allergies:
Height
Weight
Do you take any blood thinners?
Yes
No
Do you use tobacco?
Yes
No
Packs or Cans per week
How long have you used tobacco?
Do you drink alcohol?
Yes
No
Drinks per week:
Recreational drug use:
Yes
No
Please explain:
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Next
Patient History (Page 2)
Spine Surgical History
Please be sure to include the date, surgery type, outcome, and hospital of your past surgeries.
Other Surgical History:
Please be sure to include the date, surgery type, outcome, and hospital of your past surgeries.
Please mark if you have currently have or have had problems with in the past:
Cardiovascular
Chest pain/angina
Heart trouble
High blood pressure
Swelling of hands, feet, ankles
Heart murmur
Heart attack
Stroke
Blood clots
Congestive heart failure
Blood Disease
Phlebitis
Excessive bleeding
Abnormal bleeding or bruising
Anemia
Hemophilia
Endocrine
Diabetes
Thyroid Disease
Other
Lupus
Fibromyalgia
HIV Positive/AIDS
Hepatitis
Pulmonary
Asthma
Emphysema
COPD
Sleep Apnea
Gastrointestinal system
Stomach ulcers
Diverticulosis
Hepatitis
Liver trouble
Heart burn
Abdominal pain
Changes in bowel habits
Constipation
Genitourinary
Loss of urine
Frequent urination
Kidney disease
Kidney stones
Enlarged prostate
Psychiatric
Depression
Anxiety
Nervous System
Dizzy / Fainting spells
Headaches
Loss of balance
Gynecological
Menopause
Tubes tied
Possibility of pregnancy?
Yes
No
Do you have or have you had cancer?
Yes
No
Please list all the medications you are currently taking:
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