Patient Medical History and Present Illness
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Mobile/Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary phone to contact you
*
Mobile
Home
Work
Email Address
*
example@example.com
Would you like to receive text or e-mail appointment reminders?
*
Text
E-mail
Both
None
Sex
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
*
Single
Married
Divorced
Widow
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Physician Name
Physician City, State & Zip Code
Employer Name
Occupation/Job Title
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
Reason #1 for visit (e.g. low back pain, neck pain, shoulder pain, hip pain, etc.)
*
When did symptoms begin?
*
-
Month
-
Day
Year
Date
How did it happen?
*
Describe your pain
*
Dull ache
Sharp
Shooting
Tight
Burning
Tingling
Throbbing
Other
Rate your pain (0-10; 0=no pain, 10=worst pain you've ever felt)
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
Have you had any imaging taken? (Leave blank if none)
X-Ray
MRI
CT Scan
Diagnostic Ultrasound
Other
If yes, where was the imaging taken?
Please select which, if any, of the following activities you feel are limited due to your symptoms. (Leave blank if none apply)
Lifting
Bending
Standing
Walking
Sitting
Climbing stairs
Running
Laying
Sports/Exercise
Working at a desk
Household chores
Other
Please select which of the following helps to relieve your symptoms.
*
Rest
Moving around
Exercise
Stretching
Pain medication
Heat
Ice
Chiropractic care
Physical Therapy
Nothing Works
Other
How consistent are your symptoms?
*
Constant (75-100% of the day)
Frequent (50-74% of the day)
Intermittent (25-49% of the day)
Occasionally (0-24% of the day)
Is your pain worse at certain points of the day?
*
Worse in the morning
Worse in the middle of the day
Worse at the end of the day
Constant through the day
Randomly fluctuates
Other
Please list any other treatments you've received for this condition e.g. Doctors, hospitals, therapists, etc.
Were you injured as a result of a:
Auto Accident
Work injury
Fall
Sports injury
Other
If you have one, please list the Attorney name and phone number.
Reason #2 for visit (e.g. low back pain, neck pain, shoulder pain, hip pain, etc.) (Skip to MEDICAL HISTORY if there are not multiple complaints)
When did symptoms begin?
-
Month
-
Day
Year
Date
How did it happen?
Describe your pain
Dull ache
Sharp
Shooting
Tight
Burning
Tingling
Throbbing
Other
Rate your pain (0-10; 0=no pain, 10=worst pain you've ever felt)
Please Select
0
1
2
3
4
5
6
7
8
9
10
Have you had any imaging taken? (Leave blank if none)
X-Ray
MRI
CT Scan
Diagnostic Ultrasound
Other
If yes, where was the imaging taken?
Please select which, if any, of the following activities you feel are limited due to your symptoms. (Leave blank if none)
Lifting
Bending
Standing
Walking
Sitting
Climbing stairs
Running
Laying
Sports/Exercise
Working at a desk
Household chores
Other
Please select which of the following helps to relieve your symptoms.
Rest
Moving around
Exercise
Stretching
Pain medication
Heat
Ice
Chiropractic care
Physical Therapy
Nothing Works
Other
How consistent are your symptoms?
Constant (75-100% of the day)
Frequent (50-74% of the day)
Intermittent (25-49% of the day)
Occasionally (0-24% of the day)
Is your pain worse at certain points of the day?
Worse in the morning
Worse in the middle of the day
Worse at the end of the day
Constant through the day
Randomly fluctuates
Other
Please list any other treatments you've received for this condition e.g. Doctors, hospitals, therapists, etc.
Were you injured as a result of a:
Auto Accident
Work injury
Fall
Sports injury
Other
If you have one, please list the Attorney name and phone number.
MEDICAL HISTORY
Height
Feet
Inches
Weight
lbs
Please select if any of the following are true to you.
Unexplained weight loss
Loss of appetite
General feeling of being sickly or unwell
Significant fatigue
Pain that awakens you at night
Night Sweats
History of Cancer
Recent infections
IV Drug use
Recreational drug use
Alcohol Abuse
Osteoporosis/osteopenia
Dizziness
Fainting
Visual Changes
Nausea/Vomiting
Difficulty speaking or swallowing
Difficulty with balance
New headaches you've never experienced before
Tingling, numbness or weakness in the arms or legs
Heart disease
Chest pain
Heart palpitations or irregular heartbeat
High blood pressure
Shortness of breath or difficulty breathing
Changes in bowel/bladder habits
Loss of bladder or bowel control
Difficulty urinating
Change in sexual function
Numbness in the inner thigh, groin, or genital region
Abdominal pain that arises in conjunction with your pain
Pulsating pain
Please list any other health conditions you are currently managing/monitoring?
Please list any medications you are currently taking
Please list any past injuries, surgeries or hospitalizations
I certify that the information I have provided on this form is true, complete, and accurate to the best of my knowledge. I understand that any fields left blank have been left blank because they do not apply to me. I acknowledge that providing accurate information is important for my care, and I agree to update this office if any of my personal, medical, or insurance information changes in the future.
*
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