Medical History Form

Medical Questionnaire

This information is confidential. Please fill out this questionnaire providing as much reliable data as possible
Full Name*

First NameLast Name
Date of birth

DayMonthYear
Date
Email*
example@example.com
Phone Number*

Area CodePhone Number
Age
Height
Weight lbs
Blood Type
Blood Pressure
Allergies
Current Medication
Prior Surgeries
Major Problems
How long have you had the pain & complaint?
Are there any warning sings that the pain is coming?

YesNo
Describe Circumstances
Where does the pain start?
Where does it spread from there?
How often does it appear?
Time of the day?
How long does the pain last?
Type of pain?*

PressureThrobbingTensionSharpBurningDull AcheStabbingBoringDrawingExcruciating
Are there areas of tenderness? Yes or No, please describe where.
Do you have any other signs during the time you have the pain? (vomiting, eye trouble, numbness, tingling, weakness?
Have you had similar problem before?
If so when?
Did your pain follow a recent accident or injury?

YesNo
Date of accident.

DayMonthYear
Date
How long after the accident or injury did it appear?
Describe the accident or injury
IMPORTANT: Have you had any of the following studies?*

XRAYCT SCANSMRI SCANS
When and where?
Have you had any of the following studies?*

EEGEMGNerve condition studiesDoppler studiesArteriogram
When and where?
List any of the following medical treatments you have had for your pain and all medications you have taken.(Please state how long your treatments lasted)

Physical Therapy
Describe
Bed rest
Describe
Chiropractic Treatment
Describe
Hospitalization
Describe
Medications
Describe

Please tick what effect the following has on your pain

	No Effect	More Pain	No Pain
Rest
Moving About
Coughing/Sneezing
Lifting
Weather Changes
Menstrual Period

Describe any other information that you think may be useful to our doctors here at QOLS
Having completed this Questionnaire please upload XRAY, CTSCANS, MRI, EEG, and any other medical test that you may have that are related to you present condition.
Upload medical files here.

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Medical Questionnaire