PATIENT INTAKE

Dr. Munish Lal, MD
1. Patient Information
Your name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Cell Phone:*
Please enter a valid phone number.
Email
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status:

SingleWidowedMarried
Sex:

MaleFemaleOther
2. Pain History
Where does it hurt most (body parts)?*
When did this pain begin? (approximate date, month, year)*
On a pain scale from 0 to 10, where 0 means no pain and 10 represents the worst pain imaginable, how would you rate your current pain level?*

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst Pain
Since your pain began how has it changed?   Improved   Worsened   Stayed the same

When is your pain at its worst?
Mornings    Daytime    Evenings    Middle of night     Always the same

How often does the pain occur?
Intermittent (comes and goes)    Changes in severity but always present     Constant
3. Injury History
Injury Date*

MonthDayYear
1. Injury from: car accident, slip and fall, motorcycle, car vs pedestrian, car vs bicycle*

If in car, were you wearing seatbelt?If in car, were you the driver?if in car, were you the front passenger?slip and fall
2. In what city did this happen?
3. Immediately following the injury, did you experience nausea, vomiting, dizziness, blurred vision, etc? Please list:
4. List all treatments done with approximate dates:
5. Have you ever had pain/injury in this/these area(s) BEFORE this injury? YesNo

Please provide information on this section that applies only since your injury (auto accident).

	Better	Worse	Body Area
Bending Backward
Bending Forward
Changes in Weather
Climbing Stairs
Coughing/Sneezing
Driving
Lifting Objects
Looking up/down
Looking side to side
Rising from sitting
Sitting
Standing
Walking

	Helped	Worsened	Same	# of WEEKS / MONTHS?
Medications
Physical Therapy
Chiropractic
Roller Table
Electric Stim/TENS
Heat/Ice
Massage Therapy
Acupuncture
Brace Support
Cognitive Therapy

Associated Symptoms

	No	Yes	LOCATION
Numbness (can’t feel skin)
Weakness in the arm/leg
Can’t hold Bladder
Can’t hold Bowels

4. Limitations
Does your condition stop you from doing everyday activities, meeting friends, or having fun?*

YesNo
Please explain more. For example, does it affect your bathing, dressing, eating, walking, bending, holding things, driving, or playing sports?
5. Pain Treatment History: If you have had any, please list each treatment and the date you last received it
Epidural Steroid (not childbirth) Injection: Dates/Years
Facet Injections/ Medial Branch Blocks Dates/Years
6. Diagnostic Tests and Imaging
MRI of the: body part Dates/Years
X-Ray of the: body part Dates/Years
CT Scan of the: body part Dates/Years
7. Past Medical History

Mark the following conditions/diseases that you have been treated for in the past:
General Medical
Cancer
Diabetes
Cardiovascular/Hematologic

Heart AttackHigh Blood Pressure
Gastrointestinal

GERD (Acid Reflux)Stomach UlcersConstipation
Respiratory

AsthmaEmphysema/COPD
Urological

Chronic Kidney DiseaseUrinary Incontinence
Urological

Chronic Kidney DiseaseUrinary Incontinence
Neuropsychological

Peripheral NeuropathySeizuresDepressionAnxietyBipolar Disorder
Head/Ears/Eyes/Nose/Throat

HeadachesHyperthyroidismHypothyroidism
Musculoskeletal/Rheumatologic

FibromyalgiaArthritisOsteoporosis
Other Diagnosed Conditions
I have no significant Past Medical History
8. Past Surgical History

Please list any surgical procedures you have had done in the past including date:

	Surgery / Procedure	Date
1
2
3
4
5

I have never had any surgical procedures performed.
9. Medications

Please list all medications you are currently taking.

	Medication Name	Dose	Frequency
1
2
3
4
5

Do you currently use any anticoagulant or blood-thinning medications? For example, medications such as aspirin, warfarin*

YesNo
Blood thinner medication name(s):

Please list all pain medications that you have been taking.

	Medication Name
1
2
3

10. Allergies

	Medication Name	Allergic Reaction
1
2
3

Existing Allergies:*

IV Contrast/IodineLatexTapeOtherNo Allergies
11. Family History
Mark all appropriate diagnoses as they pertain to your first-degree relatives:

CancerDiabetesHeadaches/MigrainesHigh Blood PressureOsteoporosisRheumatoid arthritisNo significant family medical history
12. Social History
EmployedUnemployedRetiredTemporary DisabilityPermanent Disability
Are you currently under worker’s compensation?*

YesNo
Tobacco Use:
Never used Current user Former user *
Alcohol Use:*

Never usedSocial UseHistory of alcoholismCurrent alcoholismDaily use of alcohol
Illegal Drug Use (not including marijuana):

No illegal drug useCurrent illegal drug useFormerly used illegal drugs
Have you ever abused prescription medications?

YesNo
13. Review of Systems

Mark the following symptoms you are experiencing today:
Constitutional:

ChillsDifficulty sleepingEasy bruisingFatigueFeversLow sex driveUnexplained Weight GainUnexplained Weight Loss
Ears/Nose/Throat/Neck:

Dental ProblemsEarachesHearing ProblemsNosebleedsSinus problems
Cardiovascular:

Chest PainBleeding DisorderBlood ClotsFaintingPalpitations
Eyes:

Blurred visionLoss of vision
Gastrointestinal:

Nausea/VomitingDiarrheaConstipationAcid RefluxAbdominal Cramps
Respiratory:

CoughWheezingShortness of breath
Musculoskeletal:

Joint StiffnessJoint Swellingmuscle spasms
Genitourinary/Nephrology:

Flank PainBlood in UrinePainful UrinationChange in Urine Flow/Frequency/Volume
Neurological:

DizzinessHeadachesTremorsSeizures
Who is filling out this questionnaire?

SelfSpouseOther
Psychiatric:

Depressed MoodFeeling AnxiousStress ProblemsSuicidal ThoughtsSuicidal PlanningThoughts of Harming OthersAll other review of systems negative
I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.
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1. Patient Information

2. Pain History

3. Injury History

4. Limitations

5. Pain Treatment History: If you have had any, please list each treatment and the date you last received it

6. Diagnostic Tests and Imaging

7. Past Medical History

8. Past Surgical History

9. Medications

10. Allergies

11. Family History

12. Social History

13. Review of Systems