History of Present Illness

History of Present Illness
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
What is your Pain Score?*
0 is no pain, and 10 is horrible pain
Draw where the pain is:*
Draw where the pain is:
Describe what caused your pain:*
Have you ever had this pain before? Please explain:*
How long have you had this pain?*
How often does this pain occur? or is it constant?*
Is the pain*

Getting betterGetting worseStaying the sameOther
What make your pain better?*
What makes your pain worse?*
Have you had Physical Therapy for this pain? If so, what is the name of the PT place? Where? How long?*
List out EVERYTHING you have tried to do for this pain including medications, devises, surgeries, etc. These are VERY important for us to get insurance authorizations for you.*
Have you had films of this pain? If so, where? MRI? CT? X-rays?*
Have you seen other doctors for this? If so, list out with their specialty*
Please list your ALLERGIES and the reactions for each:*
Please list your current medications:*
Are you on any Anticoagulants (blood thinners)?*

NoneCoumadinPlavixElliquisXeraltoEffientBrillintaPradaxaFragminSavaysaArixtraAggrenoxTrenalPentoxilInnohepPletalTiclidPentoxilAspirinOther
Do you have High Blood Pressure?

YesNo
Do you have Diabetes? If so, please list your treatment
List All Heart or Lung problems and treatments. This includes stents, pacemakers, defibrillator, etc
List out ALL other medical illness with details:
Should be Empty: