Pain and Inflammation Patient Intake Form

Pain and Inflammation Patient Intake Form

The medical information you supply is subject to ALL patient/doctor privilege laws
Date of Birth*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Employment Status - Employer? Self-Employed? Retired?
Emergency contact

Full NamePhone Number
ParentSignificant OtherSiblingChildFriendOther
MEDICAL HISTORY
Please list all current Medical Conditions:
Surgical History
YesNo
If YES, please list all prescription medications and / or supplements you are currently taking ?
YesNo
YesNo
If YES, what dose and how often do you take aspirin?
YesNo
If YES, please list:
YesNo
If YES, please list any known allergies
YesNo
If yes, please list type of cancer treatment, how long ago were treated and current status
YesNo
Please provide a detailed description of the reason for seeking treatment
How long have you had this problem?
SuddenGradual
Rate your average discomfort on a scale of 0 (no pain) to 10 (severe pain)
ConstantIntermittent
KneeElbowShoulderAnkleFootHipHand/wrist
RightLeftBoth
What is the Medical Diagnosis and approximate date of diagnosis?
YesNo
YesNo
YesNo
If you have had radiological studies or previous medical reports, make sure to bring them with you when you visit the office for your appointment
YesNo
If yes, what kind of shots did you receive and when?
YesNo
If yes, please detail the type of procedure and when you had the procedure, and results you experienced.
Past Medical History: Please answer all of the following questions:
General weaknessLeg crampingNumbnessShortness of breathSwelling hands,feet,ankleMuscle weaknessJoint weaknessDifficulty walkingCalf or buttocks painHistory of fallsPoor balancePsychiatric careDepressionChemical DependencyHepatitisHIV/AIDSWeight lossThyroid problemsDizziness/faintingHearing lossCancerProstate cancerFamily history of cancerBowel issuesFrequent urinationUnable to urinateProstate BPHHigh blood pressureHigh cholesterolChest pain, anginaStrokeHeart surgeryHeart diseaseAtrial fibrillationEpilepsy, SeizuresKidney diseaseLung diseaseFeversEmphysemaBronchitisGoutArthritisDiabetesVaricose veinsStomach ulcerIrritable bowel syndromeSleep disturbances
Is there any other conditions you would like to tell the doctor about?
SOCIAL HISTORY
YesNo
YesNo
YesNo
Should be Empty: