Patient History

Patient History

Please fill the form below accurately to enable us serve you better!
Date of Birth

MonthDayYear
Date
Age
Social Security #
Patient Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone (Home)
Please enter a valid phone number.
Phone (Work)
Please enter a valid phone number.
Email*
example@example.com
May we send you our online newsletter?

YesNo
Your Occupation
Employer
Spouse's Name
Spouse's DOB

MonthDayYear
Date
Spouse's SSN
Have you been to another doctor for this problem?

YesNo
Who/Where?
Who may we thank for referring you to this office?
WHAT BRINGS YOU TO OUR OFFICE? Please provide as much detail as possible.
PRIMARY COMPLAINT:
Date when symptom first appeared

MonthDayYear
Date
Did it begin:

GradualSuddenProgressive over time
What makes the symptoms increase?
What relieves the symptoms?
Type of Pain:

SharpDullAcheBurnThrob
Does the Pain Radiate into your

ArmLegDoes not radiate
Do you have Numbness or Tingling?

YesNo
How often do you experience these symptoms?

100%75%50%25%10%
Please rate the intensity of your symptoms on a scale of 1-10 (1 being no symptoms, 10 being extreme)
Please list all previous treatments for this condition (give doctor's name and dates if possible)
Do you have any family members who suffer from the same complaint? If so, who?
SECONDARY COMPLAINT:
Date when symptom first appeared

MonthDayYear
Date
Did it begin:

GradualSuddenProgressive over time
What makes the symptoms increase?
What relieves the symptoms?
Type of Pain:

SharpDullAcheBurnThrob
Does the Pain Radiate into your

ArmLegDoes not radiate
Do you have Numbness or Tingling?

YesNo
How often do you experience these symptoms?

100%75%50%25%10%
Please rate the intensity of your symptoms on a scale of 1-10 (1 being no symptoms, 10 being extreme)
Please list all previous treatments for this condition (give doctor's name and dates if possible)
Do you have any family members who suffer from the same complaint? If so, who?
Do you smoke?

YesNo
If yes, how many packs per week
Have you ever smoked in the past

YesNo
If yes, when did you quit?
Do you take birth control?

YesNo
Have you ever taken birth control in the past?

YesNo
Do you consume alcohol?

YesNo
If yes, how many drinks per week?
Do you consume caffeine?

YesNo
If yes, how many drinks per day?
Do you exercise?

YesNo
If yes, how many times per week and what type?
Do you have a high stress level?

YesNo
If yes ,list reasons:
Would you like the doctor to know any thing else?
Please list any medications or vitamins you are currently taking:
Did it begin:

GradualSuddenProgressive over timeAuto Accident
Please list all surgeries, injuries, accidents, falls, etc:
Please check if you have had any of the following:

AIDS/HIVAlcoholismAnemiaAllergy ShotsAnorexiaArthritisAsthmaBleeding DisordersBreast LumpBronchitisBulimiaCancerCataractsChemical DependencyChicken PoxDiabetesDisc DegenerationEmphysemaEpilepsyGlaucomaGoiterGonorrheaGoutHeart AttackHeart DiseaseHepatitisHerniaHerpesHigh Blood PressureHigh CholesterolKidney DiseaseLiver DiseaseMeaslesMigraineMiscarriageMononucleosisMSMumpsOsteoporosisPacemakerParkinson’s DiseasePinched NervePneumoniaPolioProstate ProblemProsthesisPsychiatric CareStrokeRheumatic FeverScarlet FeverSuicide AttemptThyroid ProblemsTonsillitisTuberculosisTumors/GrowthsTyphoid FeverUlcersVascular DiseaseVaginal InfectionsVenereal DiseaseWhooping CoughRheumatoid ArthritisOther
Signature*

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Date

MonthDayYear
Date
Should be Empty:

Patient History

WHAT BRINGS YOU TO OUR OFFICE? Please provide as much detail as possible.