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Primary Care Physician:
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Hand Dominance: Right/Left
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What is the main reason for your visit today:
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Body Diagram - Symptoms
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THE PAIN IS: (Check all that apply)
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Severity: How severe is your pain?
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EFFECT ON DAILY LIFE
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WORSENING IN THAT IT IS:
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Does the condition wake you up at night?
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Condition interferes with recreational activity?
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Does the condition Interfere with work activity
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Functional activities
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I can comfortably → Stand for _____ minutes
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Walk for _____ minutes.
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Sit for _____ minutes
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I can do the following:
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Housework:
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Work
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Leisure Activities:
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HOW DID THE PAIN START?
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If Other, Please Specify
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WHAT ACTIVITIES MAKE THE PAIN WORSE?
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If Other, Please Specify
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WHAT REDUCES THE PAIN?
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If Other, Please Specify
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HOW LONG HAVE YOU HAD THESE SYMPTOMS/INJURY
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Date of injury
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How long have you had these symptoms?
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Was this due to a motor vehicle accident?
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If yes, do you have an accident policy:
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If yes, please provide details?
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DIAGNOSTIC TESTS
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Was X-ray taken for this problem?
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If yes, date?
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Was MRI taken for this problem?
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If yes, date?
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Was CT Scan taken for this problem?
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If yes, date?
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Was Ultrasound done for this problem?
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If yes, date?
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Was Myelogram test done for this problem?
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If yes, date?
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Was EMG done for this problem?
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If yes, date?
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Was any other test taken for this problem?
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Please specify.
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Date?
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TREATMENT HISTORY
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Taken Cortisone injection for this injury?
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If yes, date?
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Taken Epidural injection for this injury?
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If yes, date?
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Taken OTC Pain medication for this injury?
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If yes, date?
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Had surgery for this injury/symptoms.
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If yes, date?
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Had physical therapy for this injury/symptoms.
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If yes, date?
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Had chiropractic treatments for this injury?
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If yes, date?
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Used Walker/Crutch/Wheelchair/Brace?
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If yes, date?
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PAST MEDICAL HISTORY
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Diagnosed or treated for any of the following?
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Comments
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FAMILY HISTORY
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Had previous medical care for this issue?
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If yes, Treating MD:
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Facility
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Date
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Treating MD:
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Facility
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Date
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Treating MD:
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Facility
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Date
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Type of Surgery
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Approximate Date of Surgery
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Type of Surgery
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Approximate Date of Surgery
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Type of Surgery
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Approximate Date of Surgery
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Type of Surgery
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Approximate Date of Surgery
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PROBLEMS WITH ANETHESIA
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TYPE OF REACTION
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GENERAL OR LOCAL
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DATE
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TYPE OF REACTION
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GENERAL OR LOCAL
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DATE
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TYPE OF REACTION
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GENERAL OR LOCAL
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DATE
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PHARMACY:
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PHONE
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ADDRESS
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TOBACCO USE:
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If yes, cigarettes or chewing tobacco
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Are you using tobacco?
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ALCOHOL USE
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Number of packets per day
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SOCIAL:
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If yes, number of drinks per week?
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Number of Children
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If yes, how many years_________
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Are you currently employed?
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How long have you worked there?
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Present Employer
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My job duties consist of:
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Present Job / Occupation
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My present job involves: Hours sitting_____
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Lifting ___ pounds
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Hours Standing _____
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If unemployed or not working - On Medical Leave?
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Have you been Laid Off?
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Since
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Are you on Total Disability?
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Since
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Social Security Disability?
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Since
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I last worked on
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Since
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REVIEW OF SYSTEMS
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Employer would allow you to return to work?
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CONSTITUTIONAL
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SKIN
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EYES
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EARS/NOSE/THROAT
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NEURO
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CARDIOVASCULAR
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RESPIRATORY
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HEMATOLOGIC
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MENTAL HEALTH
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STOMACH / GI
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REPRODUCTIVE
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UROLOGY
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MUSCULOSKELETAL
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ENDOCRINE
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Had any trouble with this problem before?
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When was your FIRST time? ___________
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Have you had RADIATION TREATMENT or CHEMOTHERAPY
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If Yes, When?
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ALL INFORMATION LISTED ABOVE IS TRUE
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