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Transcription:

Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency 1 2 3 4 5 6 7 8 9 10 11 12 13 14 ALLERGIES: Do you have any drug allergies? Yes No If yes, please describe the allergy and the reaction: Do you have any other allergies we should know about? Yes No If yes, please describe the allergy and the reaction: FAMILY HISTORY: Family Member Alive/Deceased Age Medical Problem(s) Mother A D Father A D Are there diseases which are common in your family? (If yes, please list.) Has any family member had a history of surgery for their back or neck, or had problems with their back or neck? Page 1 of 5

Patient Name: SOCIAL HISTORY: Occupation: A: Physically, do you consider your job: Heavy Moderate Light B: If retired, what was your prior occupation? Is someone available to care for you in your home if the need arises? Yes No Do you live in a: House Apartment Other: #of stories: 1 2 3 Do you exercise regularly? Yes No Describe: Do you have a history of drug abuse or drug addition? Yes No Alcohol use: Tobacco use: I use alcohol: Never Occasional Moderate Heavy I have a history of heavy alcohol use: Yes No Do you smoke? Yes No I currently smoke packs per day and have smoked for years Are you at risk for AIDS/HIV (e.g. sexual history, drug use, previous transfusion)? Yes No PAST MEDICAL HISTORY: Please circle yes or no Y N Use of Blood Thinners Y N Anxiety Disorder Y N Aortic Aneurism Y N Arthritis Y N Asthma Y N Bipolar Disorder Y N Cancer Y N Congestive Heart Failure Y N COPD (Chronic Obstructive Pulmonary Disease) Y N Head Injury, without skull fracture Y N HIV Y N High Cholesterol Y N High Blood Pressure Y N Heart Attack Y N Infectious Diseases (e.g. MRSA, TB) Y N Osteoarthritis Y N Coronary Artery Disease Y N Osteoporosis Y N (CVA ) Stroke Y N Rheumatoid Arthritis Y N Degenerative Joint Disease Y N Depression Y N Seizue Disorder Y N Diabetes Y N Sleep Apnea Y N Fibromyalgia Y N Thyroid Disease Y N Glaucoma Y N Tuberculosis Y N Head Injury, with skull fracture Y N Vertebral Artery Stenosis Complications from any surgery? No Yes Please Explain Do you take antibiotics before procedures or dental work? No Yes Why? Page 2 of 5

Patient Name: PAST SURGICAL HISTORY: Please list all previous surgical procedures and the date your surgery was performed. Carpal Tunnel Spinal Cord Injury Craniotomy Spinal Cord Stimulator Discectomy Spinal Fusion Lumbar Endarterectomy Spinal Fusion Thoracic Intracathecal Pump Ulnar Nerve Release Kyphoplasty Vertebroplasty Laminectomy Cervical Laminectomy Lumbar Other Appendectomy Heart Surgery C Section Angioplasty Gall Bladder Removal Bypass Dental Stent D&C Valve Replacement Eye Surgery Other Fracture Repair Hernia Repair Rotator Cuff Repair Hysterectomy Thyroidectomy Sinus Surgery Subtotal Pancreatic Surgery Total Prostatectomy Tonsillectomy Large Bowel Resection Tubal Ligation Small Bowel Resection Vasectomy Stomach Resection Other REASON FOR VISIT: Describe your current problem and how it began. Please list all symptoms leading to today s visit: Page 3 of 5

REASON FOR VISIT cont d: Date symptoms began: Is your current problem a result of: Car Accident Work Accident Other/Unknown Date of injury/accident: Are you currently off work because of your problems? Yes No Is a lawyer involved in your case? Yes No If yes, name of lawyer: PAIN HISTORY: (if not applicable, skip to next section) What makes your symptoms better? What makes your symptoms worse? What specific activities are you having difficulty with that you hope to change as a result of treatment? In order to get better, you will be expected to participate in your treatment. This may include doing exercises or avoiding certain activities. How committed are you to participating in your treatment? Very Committed Somewhat Committed Not Very Committed Is there anything that will limit your ability to participate in therapies? Yes No Please Explain: What tests have you had for your problem? X rays Ct Scan MRI Blood Tests Other: What treatments have you had for your problem? Medication(s) Physical Therapy Chiropractic Injections Surgery Other: Please describe their effect: Would you consider surgery if it were recommended? Yes No REVIEW OF SYSTEMS: Please circle yes or no General: Y N Weight gain greater than 10 lbs Y N Weight loss greater than 10 lbs Y N Obesity Skin: Y N Bruising Neck: Y N Neck Mass Y N Swollen Glands Respiratory: Y N Chronic Cough Y N Difficulty Breathing Page 4 of 5

Patient Name: HEENT: Musculoskeletal: Y N Blurred Vision Y N Back Pain Y N Head Injury Y N Muscle Cramps Y N Double Vision Y N Arm Weakness Y N Visual Disturbances Y N Leg Pain Y N Visual Loss Y N Neck Stiffness Y N Hearing Loss Y N Ringing in the Ears Neurological: Y N Seasonal Allergies Y N Decreased Memory Y N Hoarseness Y N Difficulty Speaking Breast: Y N Nipple Discharge Y Y N N Dizziness Fainting Cardiovascular: Y N Headaches Y N Chest Pain Y N Incoordination Y N Irregular Heart Beat Y N Loss of Consciousness Y N Elevated Blood Pressure Y N Seizures Y N Rapid Heart Beat Y N Stroke Y N Shortness of Breath Y N Weakness in Extremeties Y N Swelling of the Feet Y N Leg Pain with Walking Gastrointestinal: Y N Change in Bowel Habits Psychiatric: Y N Indigestion Y N Anxiety Y N Jaundice Y N Depression Y N Nausea Y N Inability to Concentrate Y N Vomiting Endocrine: Genitourinary: Y N Thyroid Problem Y N Change in bladder habits Hematology: Y N Frequency Y N Abnormal Bleeding Y N Hesitancy Y N Anemia Y N Incontinence Y N Blood Clots Other: The above information is accurate to the best of my knowledge: Please Print Name Signature Date I HAVE REVIEWED THE ABOVE INFORMATION (Office Use Only) Page 5 of 5 Physician Name Signature Date Reviewed Page 5 of 5

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