• Vital Total Health Medical Group, Inc.

    Vital Total Health Medical Group, Inc.

    www.VitalTotalHealth.com www.VitalOncall.com

  • 710 S Broadway, Ste 212, Walnut Creek, CA  94596

    4200 18th Street, Ste 103, San Francisco, CA  94114

    2929 Summit Street, Ste 103, Oakland, CA  94609

    4439 Stoneridge Road, Ste 110, Pleasanton, CA  94588

    6611 Folsom-Auburn Road, Ste F, Folsom, CA  95630

    291 S La Cienega Blvd, Ste 108, Beverly Hills, CA  90211

    Telephone and Central Fax (925) 388-9800

  • NEUROLOGY QUESTIONNAIRE

  • Today's Date
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • What is your dominant hand:*
  • PRESENTING PROBLEMS: Check all that applies
  • If your Problem is Pain, then Rank the Area of Pain with #1 being the main problem:
    Rows

  • NEXT FOUR SECTIONS are NECK PAIN, UPPER LIMB PAIN, LOW BACK PAIN, LOWER LIMB PAIN.  You need to ONLY answer the sections that apply to you.  Eg. If your Neck Pain radiates to your arm, fill out only the NECK section.  Or if you have an elbow injury, then fill UPPER LIMB PAIN only.

  • NECK PAIN: (Starts at neck and radiates to arms)

  • Date NECK PAIN Began
     / /
    2 digit month, 2 digit day, 4 digit year
  • FREQUENCY OF NECK PAIN:
    Rows
  • PAIN SCALE OF NECK PAIN: One to 10
    Rows
  • CHARACTER of NECK PAIN - check all that applies
  • NECK PAIN Radiates to:
    Rows
  • Associated with:
  • Aggravating and Relieving Factors to Neck Pain:
    Rows
  • Relieving Factors to Neck Pain:
    Rows
  • NECK PAIN SYMPTOMS ARE

  • UPPER LIMB PAIN: (Starts in Upper Limbs)

  • Date Upper Limb Pain Began:
     - -
    2 digit month, 2 digit day, 4 digit year
  • UPPER LIMB PAIN (Separate from Neck, starts in Upper Limbs - check where the problems are)
    Rows
  • FREQUENCY OF UPPER LIMB PAIN:
    Rows
  • LeftPAIN SCALE OF UPPER LIMB PAIN: One to 10
    Rows
  • CHARACTER OF UPPER LIMB PAIN - check all that applies
    Rows
  • UPPER LIMB PROBLEM radiates to and/or associated with:
    Rows
  • ASSOCIATED WITH
    Rows
  • Aggravating and Relieving Factors to UPPER LIMB Pain: Check if applies
    Rows
  • UPPER LIMB SYMPTOMS ARE

  • LOW BACK PAIN: (Starts at back and radiates to legs)

  • Date LOW BACK PAIN Began
     / /
    2 digit month, 2 digit day, 4 digit year
  • FREQUENCY of LOW BACK PAIN
    Rows
  • PAIN SCALE OF LOW BACK PAIN: One to 10
    Rows
  • CHARACTER of LOW BACK PAIN - check all that applies
  • LOW BACK PAIN Radiates to:
    Rows
  • ASSOCIATED WITH:
  • Aggravating and Relieving Factors to LOW BACK PAIN:
    Rows
  • LOW BACK SYMPTOMS ARE

  • LOWER LIMB PAIN: (Starts in legs and radiates to legs)

  • Date LOWER LIMB PAIN Began
     / /
    2 digit month, 2 digit day, 4 digit year
  • LOWER LIMB PAIN:
    Rows
  • FREQUENCY of LOWER LIMB PAIN
    Rows
  • PAIN SCALE OF LOWER LIMB PAIN: One to 10
    Rows
  • CHARACTER OF LOWER LIMB PAIN - check all that applies
    Rows
  • LOWER LIMB PAIN Radiates to:
    Rows
  • ASSOCIATED WITH:
    Rows
  • Aggravating and Relieving Factors to LOWER LIMB PAIN:
    Rows
  • LOWER LIMB SYMPTOMS ARE
  • Date when symptoms began
     - -
    2 digit month, 2 digit day, 4 digit year
  • Pain throughout Day:
    Rows
  • Does the Pain impact:*
    Rows
  • PRIOR TREATING DOCTORS:
    Rows
  • PRIOR WORKUP:*
    Rows
  • PRIOR TREATMENT FOR PRESENT PAIN*
    Rows
  • PAST MEDICAL HISTORY: Medical problems treated now or in past*
    Rows
  • Have you had any Surgeries?*
  • PAST SURGERIES:
    Rows
  • FAMILY HISTORY:
    Rows
  • SOCIAL HISTORY:*
    Rows
  • Do you have any ALLERGIES TO DRUGS OR ANESTHESIA:
  • List Drugs Allergies:
    Rows
  • Are you taking any PRESENT MEDICATIONS, or Over-the-Counter Supplements?*
  • PRESENT MEDICATIONS:
    Rows
  • Have you tried any Medications in the Past for your Pain?*
  • PAST DRUGS USED for your pain:
    Rows
  • REVIEW OF SYSTEMS (General Health): Do you have any problems with*
    Rows
  • Today's Date
  • Should be Empty: