Patient Health History
Patient Information
Primary Reason For Your Visit
*
Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Occupation
*
Ethnicity
Caucasian
African American
Asian
Hispanic
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?
*
Yes
No
If so, where?
*
Do you have any numbness/tingling?
*
Yes
No
If so, where?
*
What makes your pain better?
*
Laying
Sitting
Standing
Walking
Rest
Heat
Ice
Position Change
NSAIDs (Ibuprofen, Celebrex, etc.)
Narcotics
What narcotics?
*
What makes your pain worse?
*
Laying
Sitting
Standing
Walking
Twisting
Lifting
Pushing/Pulling
Sit to stand
Getting out of bed
Carrying
Previously Tried Treatments
Physical Therapy
*
Yes
No
What year?
*
Was it helpful?
*
Please Select
Yes
No
Provider name and office
What area were you being treated for?
*
Steroid Injections
*
Yes
No
What year?
*
Was it helpful?
*
Please Select
Yes
No
Provider name and office
Location of Injection
*
Stimulator
*
Yes
No
What year?
*
Was it helpful?
*
Please Select
Yes
No
Type
*
Spinal
Peripheral
Provider name and office
Opioid Pain Pump
*
Yes
No
What year?
*
Was it helpful?
*
Please Select
Yes
No
Provider name and office
Other Therapies
Chiropractic
Massage
At Home Exercises
Aquatic
Acupuncture
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