History of Present Illness
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
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 better
Getting worse
Staying the same
Other
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)?
*
None
Coumadin
Plavix
Elliquis
Xeralto
Effient
Brillinta
Pradaxa
Fragmin
Savaysa
Arixtra
Aggrenox
Trenal
Pentoxil
Innohep
Pletal
Ticlid
Pentoxil
Aspirin
Other
Do you have High Blood Pressure?
Yes
No
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:
Submit
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