• MEDICAL INTAKE FORM

    MEDICAL INTAKE FORM

  • PLEASE CHECK BOXES NEXT TO SYMPTOMS THAT YOU HAVE EXPERIENCED IN THE LAST 12 MONTHS.
  • General:
  • Heart
  • Nervous System
  • Eyes
  • Ear/Nose/Mouth/Throat
  • Skin:
  • Stomach/Intestines
  • Kidney / Urine / Bladder
  • Blood
  • Lungs
  • Psychiatric:

  • *** For Women Only***

  • During pregnancy any history of

  • If history of miscarriage , how early was it?       

  • Postmenopausal
  • Contraception:

  • PREVIOUS TREATMENT / INJECTIONS FOR PAIN

  • Previous Steroid joint injection
  • Previous Epidural Injection:
  • Previous Physical Therapy
  • If you have no allergies, please check here.

  • Personal History

  • Marital status
  • Are you employed?
  • If yes, job title:
  • If not employed, are you:
  • If retired, previous occupation:

  • PAST MEDICAL HISTORY – Please mark the conditions that you have.

  • List any other previous or current medical diagnosis

  • List any history of cancer, date of diagnosis, treatments and years into remission and name of oncologistE.g. breast cell cancer diagnosed in 2018 by dr xyz, received chemo-radiation

  • Past Surgical History

  • Family History (Current or Past)

  • Rows

  • Social History

  • Which product do you use? Check all that apply:
  • Do you drink alcohol?
  • If yes, please check:
  • Do you currently or have you used drugs recreationally? 
  • If yes, please list:
  • Please check any medication used:
  • Self-injectables: Example , Humira, Enbrel
  • Infusion: Example, Infliximab/ Remicade

  • *** If no joint pain skip this section***

  • Quality of pain

  • Joint pain began:

  • What makes pain worse?
  • Joint swelling?
  • Pain Travels?

  • If yes, pain travels to:   .

  • What makes pain better?

  • List any associated symptoms with joint pain (e.g rash)            

  • Average level of pain in the past week?
  • Level of pain from 1-10:
  • Arms:
  • Legs:

  • Mark areas of PAIN that you have on the diagram using SHADING.

  • (Click back arrow to undo)
  • Should be Empty: