New Patient - Schmitt

Integrative Spine & Body Medicine

Dr. Susan Schmitt
NEW PATIENT FORM
Patient Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Age
Today

MonthDayYear
Date
Referral Doctor

List your primary complaints today (in order of most severe):

Rows
1.
2.
3.
4.

When did your pain problem first occur (exact date if known)?
For Auto Injury:
Seat Belt:
Vehicle Owner:
Vehicle Type:
How did it happen (check one)?

Other
Where did the injury occur?
What activity were you doing when this happened?
Describe what caused your injury
How did your problem start?

Other
How is your problem doing now?
Have you injured this area/areas before?
Description of pain (check all that apply)
Please fill out the pain diagram to the right (We will have you fill in the diagram at the time of your visit):

(shade painful body regions to show where the pain is)

(apply “X” for numbness/tingling areas)
Front
Back
Is there weakness:

Maximum time you can:

Rows	Sit	Stand	Walk	Lift (lbs)
hr/min/lbs

Is there numbness
If Yes (where)
Trouble sleeping?
# hours of sleep at night
Positions that worsen your pain
Positions that lessen your pain
Work status (check all that apply):
If Part time, # of hrs
If Not working (why?)
Job title current
Employer name
Length of employment (years)
(months)
List dates of missed work:
Currently on work restrictions
If Yes (list dates)
List previous 2 jobs

List all names of health care providers (doctors, chiropractors, physical therapists, massage therapists, counselors, etc you have seen since the accident for this condition:

Rows
1.
2.
3.
4.
5.

Diagnostic tests done for your problem:

Rows	Approx Date	Facility
X-ray (body part)
CT (CAT Scan)
MRI
Bone Scan
EMG/Nerve conductions

Medical history (please indicate if you have had any of the following conditions):
Previous Motor Vehicle Accident:
If Yes, Year
List injuries
Previous Work Comp Injury:
If Yes, Year
List injuries
Other
Surgical history (indicate all prior surgical procedures and approximate dates)
Other
Current medications (list all prescription and non-prescription drugs you are currently taking):
List all medications you are allergic to
Problems with:
Steriods
NSAIDS
Latex
Family history of:
Cancer (type)
Other (describe)
Social History: Marital status:
Number of children
Do you smoke?
If Yes (packs per day)
Previously smoke?
If Yes (year quit)
Do you drink alcohol?
High risk behavior:
Recreational drugs?
IV drugs?
Close contact with IV drug users?
Current Height
Current Weight
Review of systems (check if you have had any of these symptoms over the past few months):
Eye:
Ear, nose, throat:
Stomach, Intestines:
Lungs:
Heart:
Urinary:
Neurologic:
Blood, lymph:
Bones, joint, muscles:
Joint pain (where)
Joint swelling (where)
Muscle pain (where)
Skin:
Mental health:
Overall health:
NOTE: If this visit is due to an auto accident, please fill out page 5. Everyone else, you are finished. Thank you!

Auto Accident Only

Please fill in the following info about the vehicles involved:

Rows	Year	Make	Model
Your car
Other car

Were you:
Were you wearing a seatbelt?
If Yes, please specify:
Did the vehicle strike you from:
Were you aware of the approaching collision prior to impact?
Were you facing forward at time of impact:
Did you lose consciousness (black out) upon impact?
If Yes, how long
What was your car doing at time of impact (check all that apply)
Describe the events of the accident to the best of your knowledge:
Did the police come to the accident?
Were you taken to the hospital?
If Yes (which one)
How did you get to the hospital?
If Driven by, describe:
Did any part of your body strike any part of your car (steering wheel, windshield, door, etc, after impact?
If Yes, describe:

When did you first notice any pain or injury from the accident (describe area of body involved)?

Rows
Immediately
Several hours later
Later that evening
Next Day

Have you been in previous accidents?
If Yes, describe:
Did you have any pain problems immediately prior to this accident?
Neck pain:
Yes (describe)
Headaches:
Yes (describe)
Other:
Were X-rays taken at the hospital?
If Yes, describe:
When is the next time you sought medical care after the accident?
List your primary complaints today from the accident in order of most severe:
1.
2.
3.
4.
5.
6.

Should be Empty:

Integrative Spine & Body Medicine

NEW PATIENT FORM

Auto Accident Only