HEALTH HISTORY. Pharmacy: Phone# Fax# Current Medications: Dosage: Frequency:
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1 HEALTH HISTORY Patient Name: Birth Date: Visit Date: Referring Physician: Reason for visit: Pharmacy: Phone# Fax# Current Medications: Dosage: Frequency: S. Blake Kelly, MD James Lynch, MD Jack Marshall, MD Brandon Funk, PA-C
2 List all pain medication taken in the last 2 weeks: If you have Depression or anxiety, how well has it been controlled in the past 3 months? Excellently Well Could be better Poorly History of allergy or adverse reactions: (circle all that apply) Antibiotic Allergy: Pain Medication: Penicillin Morphine (Kadian, Embeda, Avinza) Demerol Sulfa Codeine (Tylenol #3) Tramadol Mycins Hydrocodone (Norco, Lortab) Toradol Tetracycline/Doxycycline Oxycodone (Percocet, Oxycotin) Talwin Cephalosporins Fentanyl (Duragesic) NSAIDs Tape/Iodine Dilaudid (Hydromorphone) Tylenol Other: Other: Other: Social History: (Circle all that apply) Drink Alcohol: Occasionally Frequently Daily Use Tobacco packs per day, how long? Use street drugs or have a history of substance abuse/addiction Admitted to the hospital for psychiatric treatment, date: Admitted to the hospital for drug or alcohol treatment, date: Are you pregnant or trying to become pregnant? Yes No Marital Status: Married Single Widowed Number of children: Level of Education: Occupation: Employer: Currently Working? Yes No Disabled? Yes No Permanent/temp? Date: Are you or have you even been a victim of domestic violence or sexual abuse? Yes No
3 Please list all current doctors involved in your care at this time: Physician Specialty Date of last appointment Previous Treatments: If yes, date of last treatment Physical/Occupational Therapy Y N Chiropractor/Manipulation Y N Acupuncture Y N Hypnosis Y N TENS unit Y N Psycho/Psychiatric Therapy Y N Tests: Lumbar MRI Y N Thoracic MRI Y N Cervical MRI Y N CT Scan Y N Myelogram Y N Nerve Conduction Y N Bone Scan Y N Discogram Y N Describe below any further pertinent health history.
4 Medical History: (Please mark appropriate response) Anemia, currently Gastrointest. Disease Neck pain Arthritis (osteo or rheum) Gout Low back pain Auto-immune disorder Headaches (daily, migraine, tension) Chronic pain, Area Anxiety Heart disease Knee pain, right left Blood disease/anemia Hepatitis A _ B C Hip pain, right left Bipolar disorder High blood pressure Foot/ankle, right left Bone disease/osteoporosis High Cholesterol Shoulder, right left Wrist/hand, right Blood Transfusion HIV/AIDS left Cancer - Type Irritable bowel Pelvic pain Coronary Artery Disease Kidney disease Spinal Stimulator Congestive Heart Failure Kidney stone, number Neck, lumbar COPD/Emphysema Liver disease Crohn's disease Loss of consciousness Dementia Pacemaker Diabetes Psoriasis DVT/Blood clot Schizophrenia Dysrhythmia Seizure disorder Depression Stroke/mini-stroke Frequent falls Thyroid disease Vascular disease
5 Surgical History: (Please mark the appropriate response) No previous Surgery Other surgical history: Spinal Fusion, Date Appendectomy Neck Thoracic Lumbar Coronary Artery Bypass Spinal Laminectomy, Date Cardiac Procedure Neck Thoracic Lumbar Gall bladder removal Epidural Steroid Injection Hernia Neck, date Lumbar, date Hysterectomy Thoracic, date Joint replacement, Area Rhizotomy (nerve ablation) Neck/Lumbar Neck Thoracic Lumbar Neck/Lumbar Tonsillectomy Vertebral Disc replacement Vascular procedure Date: Neck Lumbar
6 On the diagram, shade in the areas where your pain is located. R L L R R L Mark your level of pain on this scale None Severe 0 10 Circle a FEW words that best describe your pain Flickering Pricking Pinching Tugging Hot Tingling Quivering Boring Pressing Pulling Burning Itchy Pulsing Drilling Gnawing Wrenching Scalding Smarting Pounding Stabbing Cramping Crushing Searing Stinging Dull Tender Cool Annoying Spreading Tight Sore Tiring Cold Troublesome Radiating Numb Hurting Exhausting Freezing Miserable Penetrating Drawing Aching Nagging Unbearable Intense Piercing Squeezing
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