Patient Health History

Patient Health History
Patient Information
Primary Reason For Your Visit*
Name*
Date of Birth*

MonthDayYear
Date
Occupation*
Ethnicity

CaucasianAfrican AmericanAsianHispanic
Referring Medical Provider and Office Name
Primary Medical Provider and Office Name*
Primary Insurance
Pharmacy
Symptoms
Please describe your symptoms. Please include details of where on your body you feel numbness, aches, weakness, burning, stabbing, or pins and needles.*

0/500
How long have you had these symptoms?*
Pain score on your WORST day (0 = no pain to 10 = worst)*
Do you have any weakness?*

YesNo
If so, where?*
Do you have any numbness/tingling?*

YesNo
If so, where?*
What makes your pain better?*

LayingSittingStandingWalkingRestHeatIcePosition ChangeNSAIDs (Ibuprofen, Celebrex, etc.)Narcotics
What narcotics?*
What makes your pain worse?*

LayingSittingStandingWalkingTwistingLiftingPushing/PullingSit to standGetting out of bedCarrying
Previously Tried Treatments
Physical Therapy*

YesNo
What year?*
Was it helpful?*
Provider name and office
What area were you being treated for?*
Steroid Injections*

YesNo
What year?*
Was it helpful?*
Provider name and office
Location of Injection*
Stimulator*

YesNo
What year?*
Was it helpful?*
Type*

SpinalPeripheral
Provider name and office
Opioid Pain Pump*

YesNo
What year?*
Was it helpful?*
Provider name and office
Other Therapies

ChiropracticMassageAt Home ExercisesAquaticAcupuncture
Should be Empty:

Previously Tried Treatments