New Patient History

Patient's Full Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
E-mail
Phone Number

Area CodePhone Number
History of Treatment
Have you had any Testing done for your current symptoms*

YesNo
Did You have a*

MRIMyelogram/CTEMG Nerve Conduction study
Where was the mri done at?*
When was it performed?*
When was it performed?*
When was it performed?*
What type of treatments have you had for your condition?*

Chiropractic treatmentPhysical TherapyEpidural Steriod InjectionsFacet InjectionsFacet RhizotomySI joint injectionsSurgeryNo Treatments
Who was the Chiropracter?*
Where did you take PT and How Long?*
Did Physical Therapy help?*

YesNoOther
Was the procedure done under fluoroscope or x-ray machine with you lying face down on a table?*

YesNo
Who performed the Epidural Steriod Injections?*
Date(s) of Epidural Injections*
Did the Epidural Steriod Injection help?*

YesNoOther
Level the procedure(s) were done*
Was the procedure done under fluoroscope or x-ray machine with you lying face down on a table?*

YesNo
If no Please describe what happened.*
Level the procedure(s) were done*
Was the procedure done under fluoroscope or x-ray machine with you lying face down on a table?*

YesNo
What type of Surgery and level*
Location of Epidural Steriod Injection*

CervicalThoracicLumbar
Location of Facet Rhizotomy.*

CervicalThoracicLumbar
Did the Facet Injection help?*

YesNoOther
Date(s) of Facet Rhizotomy*
Did the Facet Injection help?*

YesNoOther
If no Please describe what happened.*
How many injections did you have?*
Past Surgical History
Have you had any neurological surgeries before?*

YesNo
Neurological Surgeries

Anterior Cervical Surgery (ACF)(Neck Spine surgery)Posterior Cervical Surgery (Neck Spine Surgery)Thoracic spine SurgeryLumbar Spine laminectomy/discectomy surgeryLumbar spine fusion surgeryCraniotomy (Brain Surgery)
List any other Neurological surgeries you may have had.
Have you had any other non neurological surgery before?*

YesNo
Other Surgery

Carpal Tunnel ReleaseUlnar Nerve DecompressionKnee Surgery
Which hand was the Carpal Tunnel Release:*

RightLeftBoth
Which hand was the Ulnar Nerve Decompression:*

RightLeftBoth
What Level was the acf?*
When and what doctor did the ACF?*
Location of Facet Injections*

CervicalThoracicLumbar
What Level was the Lumbar Spine Laminectomy/discectomy Surgery??*
Did the Chiropracter help?*

YesNoOther
When and what doctor did the Laminectomy/discectomySurgery*
Where was the myelogram/CT done at?*
What Level was the Lumbar Spine fusion Surgery?*
Who performed the facet injection?*
When and what doctor did the Lumbar Spine fusion Surgery*
Date(s) of Facet injections Injections*
What Level was the Thoracic Surgery?*
Who performed the Facet Rhizotomy*
When and what doctor did the Thoracic Surgery*
Who performed the Surgery?*
Other types of testing done for current symptoms. Please put location of where the testing was performed.
What Level was the Posterior Cervical Surgery??*
If no Please describe what happened.*
When and what doctor did the Posterior Cervical Surgery*
Who did the EMG Nerve Conduction study?*
Date of Surgery*

MonthDayYear
Please mark the surgeries you have had before.
Head and Neck Surgery:

TonsillectomyNasal SurgerySinus SurgerySleep Apnea surgeryThyroidectomy (Thyroid Surgery)Cataract Surgery
Breast Surgery:

Breast BiopsyBreast LumpectomyMastectomyBreast augmentationBreast reconstruction
Cardiovascular Procedure/Surgery

Cardiac AgioplastyCardiac stentsCardiac Bypass SurgeryCardiac Valve replacementPacemakerImplantable DefibrillatorAirtic Aneurysm repainCarotid repairVascular bypass
Gynecology/Urology

HysterectomyCaesarean SectionTubal LigationOophorectomy (Ovary Removal)Retropubic suspension (Bladder Suspension)LaparoscopyCystoscopyProstatectomy (Prostate surgery)Lithotripsy (Kidney Stone Crushing)Nephrectomy (Kidney Removal)
Abdominal/Colon Surgery:

AppendectomyCholecystectomy (Gallbladder removal)HerniaHiatal Hernia/Reflux SurgeryWeight Loss SurgeryStomach Surgery for an ulcerSurgery for AdhesionsPartial colectomy ( Partial Colon Removal)Hemorrhoidectomy (hemorrhoid Surgery)
Cataract Surgery*

RightLeft
Other treatments not listed
Carotid Repair*

RightLeft
Was the Partial colectomy for:*

TumorDiverticulitisOther
Which knee did you have surgery on:*

RightLeftBoth
Please tell us the year of your surgery(s).
List any other surgeries or major illness,hospitalizations, accidents or injuries/fractures not listed already.
Past Medical History
Please check any of the below illness which you have or have had in the past. Use the spaces below this table to describe any details of checked illness or other unlisted conditions and illnesses including when it was diagnosed, how it was/is treated.
General

DiabetesHigh CholesterolGoutJaundiceLupus ErythematousThyroidReaction to AnesthesiaCancerOther medical Illness
Cardiovascular

AnemiaAnginaHeart MurmurHypertension ( high Blood Pressure)Coronary artery diseasePeripheral Vascular DiseaseMitral Valve ProlapseDeep Venous ThrombosisStrokeHeart AttackCongestive Heart Failure
Neurological

Pituitary Tumor/DiseaseAlzheimer's DementiaMultiple SclerosisParkinson's DiseaseEpilepsy/SeizuresBrain AneurysmsBrain AVMsBrain TumorsMigrainesSpine TumorsMeningitis
Musculoskeltal

FibromyalgiaOsteoporosisRheumatoid ArthritisOsteoarthritis
Genito-Urnary

Kidney ProblemsRenal InfectionProstate DiseaseKidney stones
Psychiatric

DepressionSchizophreniaManic DepressionOther Psychiatric Illness
Infection

HepatitisAIDSTB
Hematological

Easy Bleeding/bruisingBleeding Disorder
Repiratory

Sleep ApneaEmphysema/COPDLung ProblemsAsthmaPulmonary
Eye

GlaucomaCataractsBlindnessArtificial
Gastrointestinal

Acid RefluxStomach UlcersUlcerative ColitisChrone's Disease
Do you have a Cardiologist?*

YesNo
Cardiologist Name( first and Last)*
Cardiologist Phone number*
If you checked any of the medical problems listed above, please describe in further details when it was diagnosed and how treated(if necessary)
Other Medical Illness*
What kind of Stroke, when did you have it ,and what did the stroke cause you to do?*
Any additional strokes?*

YesNo
What kind of Stroke, how many additional strokes,when did you have it ,and what did each additional stroke cause you to do?*
What type of Cancer?*

Benign Brain TumorBrainBreastColonGynecologicalLeukemiaLungLymphomaMultiple MyelomaProstateSkinUrologicalother
Benign Brain Tumor: When and How was it treated?*
Brain: When and How was it treated?*
Breast: When and How was it treated?*
Colon: When and How was it treated?*
Gynecological: When and How was it treated?*
Leukemia: When and How was it treated?*
Lung: When and How was it treated?*
Lymphoma: When and How was it treated?*
Multiple Myeloma: When and How was it treated?*
Prostate: When and How was it treated?*
Skin: When and How was it treated?*
Urological: When and How was it treated?*
Other: What,When and How was it treated?*
How is your sleep apnea treated?*
Do you experience heavy snoring, daytime fatigue or periods of apnea during sleep?*

YesNo
Describe*
Do you have difficulty walking more than one block due to shortness of breathe?*

YesNo
Explain the diagnoses and treatment*
Have you had any recent acute illness,colds,coughs,asthma attacks etc?*

YesNo
Explain the diagnoses and treatment*
Have any direct family members have any problem with anesthesia?*

YesNo
Please explain your complication to anesthesia.*
Have any direct family members have any know inherited disorders that affect anesthesia care such as Pseudo-cholinesterase deficiencey?*

YesNo
Explain:*
Do you have an implanted Defibrillator or pacemaker?*

YesNo
Any foreign objects( includes gun or shrapnel fragments), in your body or your eyes?*

YesNo
Explain:*
Are you claustrophic or had any problems with failed previous attempts in a closed MRI machine?*

YesNo
Explain:*
Do you smoke?*

YesNo
If Yes, How Often?
Do you drink?*

YesNo
If Yes, How Often?
Should be Empty:

History of Treatment

Past Surgical History

Past Medical History