New Patient Evaluation
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- Della Abigayle Shelton
- 5 years ago
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1 Do you have low back pain? If no, please skip to page 2 When did your low back pain start? How did your low back pain start? How often do you experience your low back pain? Describe what your low back pain feels like. What makes your low back pain worse? What makes your low back pain better? Work related injury Motor Vehicle Accident Fall known cause Other Burning Aching Electrical Sharp Throbbing Spasms Other: Bending Backward Overhead Activity Sneezing Coughing Bending Forward Looking Up Other: Medication Massage Heat Ice Traction Lying flat on back Other: Does your low back pain extend into your legs? If yes, how often does this pain go into your legs? If no, please skip to page 2 If yes, what does the pain in your legs feel like? Burning Shooting Numbing Aching Electrical Other: What is your pain intensity today, with 0 representing no pain and 10 representing the most severe pain imaginable? Do you have any other areas of pain? If yes, please proceed below. If no, please proceed to the bottom of page 3. 1
2 Do you have neck pain? If no, please skip to the bottom of page 3 When your neck pain start? How did your neck pain start? How often do you experience your neck pain? Describe what your neck pain feels like. What makes your neck pain worse? What makes your neck pain better? Work related injury Motor Vehicle Accident Fall known cause Other Burning Aching Electrical Sharp Throbbing Spasms Other: Bending Backward Overhead Activity Sneezing Coughing Bending Forward Looking Up Other: Medication Massage Heat Ice Traction Lying flat on back Other: Does your neck pain extend into your arms? If yes, how often do you experience your arm pain? If no, please go to page 3 If yes, what does your arm pain feel like? Burning Shooting Numbing Aching Electrical Other: Do you have headaches that occur as a result of your neck pain? If yes, what does your headache pain feel like? Where do you experience your headache pain? What triggers your headache pain? Burning Shooting Throbbing Pulsing Crushing Dull & Achy Electrical Sharp Pulling Toothache like Stabbing Spasms Tingling Numbing Other: Sinuses Behind the eyes Forehead Side of head Top of head Back of head Entire head Other: Stress Strong smells Too little/much sleep Weather changes Caffeine Neck movement Certain foods/alcohol Other: How frequent are your headaches? Constantly Daily 1-2/week 3-5/week 1-2/month 2
3 Do you have any other areas of pain? If yes, please list: When did this pain start? How did this pain start? How often do you experience this pain? Describe what this pain feels like. What makes this pain worse? What makes this pain better? Pain Treatment History Please check all of the treatments you have tried for your pain and then complete the appropriate column at the right to the best of your ability. t Tried Excellent Relief Moderate Relief Relief Made Worse Surgery Injections Physical Therapy Chiropractic Therapy Psychotherapy If you have had injections, please specify what kind: What year were they done? Functional/Occupational Limitations During the past month, place a check mark next to the activities that you avoided because of pain: Going to work Performing household chores Caring for self Having sexual relations Socializing with friends Participation in recreation Physically exercising Other: Work related injury Motor Vehicle Accident Fall known cause Other Burning Aching Electrical Sharp Throbbing Spasms Other: Bending Backward Overhead Activity Sneezing Coughing Bending Forward Looking Up Other: Medication Massage Heat Ice Traction Lying flat on back Other: Have you had to stop working or change work related activities? Have you filed any legal claims related to your pain problems? Does your pain keep you up at night? 3
4 Past Medical History Please place a check by the medical conditions you have been diagnosed with. Coronary Artery Disease Heart Attack High Cholesterol Pacemaker Defibrillator High Blood Pressure Stroke Migraines Dementia Osteoarthritis Transient Ischemic Rheumatoid Asthma Sleep Apnea COPD Attack (TIA) Arthritis Degenerative Joint Emphysema Bleeding Disorder Glaucoma Fainting Disease Gastro esophageal GI bleeding Kidney Stones Hepatitis HIV/AIDS Reflux Disease (GERD) End Stage Renal Disease Diabetes Hypothyroidism Hyperthyroidism Shingles Benign Prostatic Hypertrophy (BPH) Psoriasis Staph infection Erectile dysfunction (ED) Cancer (please list type): Other: Past Surgical History Please list any surgical procedures you have had done and the year they were performed. Surgery Year 4
5 What is your relationship status? What city do you live in? What is the highest level of education you have completed? Social History Single Married Separated Divorced Widowed Who do you live with? High School diploma GED 2 year degree 4 year degree Graduate degree Other: Social History Continued Please check yes or no to the following: Do you smoke? If yes, how much: If you quit, how long ago was that: Do you use other nicotine products? Have you ever been in a detoxification program for drug abuse? Have you ever been treated at a Methadone clinic? Have you ever abused pain, sleep, anxiety, cold, psychiatric, diet or any other prescription medications? Has a parent, sibling or child abused alcohol or been diagnosed with alcoholism? Has a parent, sibling or child used illegal drugs? Has a parent, sibling or child ever abused pain, sleep, anxiety, cold, psychiatric, diet or any other prescription medications? Does anyone sharing the home take prescription pain medication? Does anyone sharing the home abuse, misuse, or sell prescription or illicit drugs? Do you suffer from physical abuse or safety hazards in your current living situation? If yes, please explain: Do you have a history of physical or emotional abuse? Were you a victim of childhood sexual abuse? Have you used drugs other than those required for medical reasons? Do you abuse more than one drug at one time? Are you always able to stop using drugs when you want to? (If you never use drugs answer ) Have you had blackouts or flashbacks as a result of drug use? Do you ever feel bad or guilty about your drug use? (If you never use drugs, choose ) Does your spouse (or parents) ever complain about your involvement with drugs? Have you neglected your family because of drugs? Have you engaged in illegal activities in order to obtain drugs? Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking your drugs? Have you ever had medical problems as a result of your drug use (memory loss, hepatitis, convulsions, bleeding, etc)? 5
6 How often do you have a drink containing alcohol? How many drinks containing alcohol do you have on a typical day when you are drinking? How often do you have 6 or more drinks on one occasion? have you found that you were not able to stop drinking once you had started? have you failed to do what was normally expected of you because of drinking? have you needed a first drink in the morning to get yourself going after a heavy drinking session? have you had a feeling of guilt or remorse after drinking? have you been unable to remember what happened the day before because you had been drinking? Have you or someone else been injured as a result of your drinking? Has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down? Please mark the most appropriate answer for each question: Monthly or 2-4 times per month 2-3 times per week 4 or more less times a week 1 or 2 3 or 4 5 or 6 7, 8, or 9 10 or more 12 oz. of Beer (~5% alcohol) = 1 drink 8-9 oz. of Malt Liquor (~7% alcohol) = 1 drink, but not in the last year (2), but not in the last year (2) Standard Drink Equivalents:, during the last year (4), during the last year (4) 5 oz. of Table Wine (~12% alcohol) = 1 drink 1.5 oz. of 80 proof Spirits (hard liquor) (~40% alcohol) = 1 drink 6
7 Psychological History Please check yes or no to the following: Have you ever accidentally overdosed on medications? Have you ever attempted suicide? If yes, did the attempted suicide involve intentional overdose on medications? Do you have suicidal thoughts? Have you ever been hospitalized for psychiatric issues? Are you currently under the care of a psychiatrist? Who? Have you been diagnosed with or suffer from Attention Deficit Disorder (ADD)? Have you been diagnosed with Obsessive Compulsive Disorder (OCD)? Have you been diagnosed with Bipolar disorder? Have you been diagnosed with Schizophrenia? Have you been diagnosed with Post Traumatic Stress Disorder (PTSD)? Have you been diagnosed with Borderline Personality Disorder? Have you been diagnosed with Antisocial Personality Disorder? Have you been diagnosed with or suffer from Anxiety? Have you been diagnosed with or suffer from Depression? Please mark the most appropriate answer to the following questions: Over the past 2 weeks, how often have you been bothered by any of the following problems? t at all Several Days More than Half the Days Nearly Every Day Little interest or pleasure in doing things Feeling down, depressed or hopeless Trouble falling asleep, staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself-or that you re a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed. Or, the opposite-being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way If you checked off any problems, how difficult have those problems mad it for you to do your work, take care of things at home, or get along with other people? t difficult at all Somewhat difficult Very difficult Extremely difficult 7
8 Please check if the family member listed has suffered from any of these medical conditions: Family History Stroke Heart Attack Cancer Diabetes Mother Father Brother Sister Review of Systems Please check all that apply to your health within the last 6 months: Fever Unintentional weight loss Night sweats Recent illness Double vision Blurry vision Vertigo Sore throat Runny nose Chest pain Rapid heart rate Palpitations Cough Shortness of breath Wheezing Nausea Vomiting Diarrhea Constipation Incontinence Painful urination Swelling Muscle pain Joint pain Rash Bruising Skin breakdown Dizziness Weakness Headaches Frequent urination Excessive thirst Anemia Heat or cold intolerance Bruising easily Bleeding problems Please list all the Physicians that are currently treating you: Name Specialty Location Allergies Please list all the allergies you currently have including to vitamins/herbs/supplements. Medication Name Reaction 8
9 Medications Please list all the medications you currently take including vitamins/herbs/supplements. Please be sure to BRING IN YOUR MEDICATION BOTTLES to your appointment. Medication Name Dose (mg, mcg, etc) Route it is taken (by mouth, injected, etc) Frequency it is taken (once a day, twice a day, etc) 9
Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol
PRE-EVALUATION FORM Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol High Blood Pressure Obesity Heart Defect
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
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COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
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New Patient Pain Evaluation
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Problem Summary. * 1. Name
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STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit.
PATIENT HEALTH HISTORY FORM DIRECTIONS AND VISIT DAY INSTRUCTIONS Prior to your Appointment: STEP 1: Forms Please complete all the attached forms and bring them with you on the day of your visit. STEP
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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