New Patient Infrmatin Sheet PLEASE COMPLETE THIS ENTIRE FORM The frm may seem lengthy but it is very imprtant t help us understand yur pain cmplaints. This will help us prvide yu with the highest level f care. Name: Date f Appintment: / / Tell us why yu are here tday: Lwer Back Pain Mid Back pain Hip and Leg Pain Neck Pain Shulder/Arm Pain Other: Fr lwer back pain, des it travel dwn int the leg? Yes N If yes, which side? Right Left Bth Fr neck pain, des it travel dwn int the arm? Yes N If yes, which side? Right Left Bth When did yur pain begin: Week(s) Ag Mnth(s) Ag Year (s) Ag Date f Onset (if knwn) Hw lng have yu had this pain (enter a number)? Days Weeks Mnths years Hw did yur pain first start: Unknwn Lifting Athletic Activity (Describe) Lifting A Fall Aut Accident: date / / Other Trauma Is yur pain? Aching Shting Stabbing Sharp Dull Burning Numbness Tingling Other (Describe) Is yur pain? Cnstant Intermittent Is yur injury/cnditin wrk related? Yes W/C case number: N Have yu had any falls in the last 12 mnths? Yes N If yes, hw many and was there any injury? 1 2 r mre withut injury with injury
What activities increase and decrease yur pain: ACTIVITY INCREASES PAIN DECREASES PAIN Sitting Standing Walking Other: Please indicate if yu have received any f the fllwing treatments fr yur pain cnditin, when the treatment ccurred, and whether the utcme was psitive (+) r negative (-) Surgery Physical Therapy Chirpractic Treatment Trigger Pint Injectins Injectins using X-Ray Treatment Apprximate Mnth & Year Treatment Outcme Epidural Sterid Injectin Facet Jint Injectin Sacriliac (SI) Jint Injectin Hip Jint Injectin Other: Have yu had any diagnstic imaging (MRI, CT, x-rays, bne scan) within the past 6 mnths? Yes N If yes, what kind? (ex. MRI f lw back) at what facility? Date f the study (if exact date unknwn, what mnth/year)? Phne number f the facility (if knwn)? Fax number f the facility (if knwn)?
What Medicatins are yu CURRENTLY taking? (attach a separate piece f paper if needed) Medicatin Name Dse (#mg) Times Taken Per Day What Medicatins did yu PREVIOUSLY take fr yur pain? Medicatin Name Dse (#mg) Times Taken Per Day
Medical Histry - Check ( ) any f the fllwing cnditins r prblems that yu have faced at any time in yur life. AIDS Emphysema Mnnuclesis Tuberculsis Alchlism Glaucma Multiple Sclersis Typhid Fever Anrexia/Bulimia Heart Disease Mumps Vascular Disease Arthritis Hepatitis Pacemaker Implant Other (list) Asthma/COPD Type: Pneumnia Bleeding Disrder Hernia Pli Cataracts HIV Psitive Prstate Prblems Cancer Type: Chicken px Diabetes Type: 1 2 Drug Dependency Hypertensin Kidney Disease Liver Disease Measles Migraine Headaches Psychiatric Cnditins Rheumatic Fever Stmach Ulcer Strke Thyrid Cnditin Surgical Histry Please list any previus surgeries and their respective dates Date Surgery
Are yu allergic t any f the fllwing? (Describe type f reactin) a. Shellfish Yes N b. Cntrast Dye Yes N c. Lcal anesthetic Yes N d. Latex Yes N e. Medicatins Yes N If Yes, list medicatins & reactin: Family Histry Please ( ) any cnditins experienced by yur parents, children, r siblings: Alive/Deceased Diabetes High Bld Pressure Heart Disease Strke Cancer Type: Other: Mther Father Sn(s) Daughter(s) Brther(s) Sister(s) Scial / Vcatinal / Wrk Histry D yu smke cigarettes? Yes N If N, did yu ever smke? Yes N If Yes, indicate hw much yu smke/smked per day by checking ne f the fllwing: Less than ¼ pack per day Abut ¼ pack per day (5 cigarettes) Abut ½ pack per day (10 cigarettes) Abut ¾ pack per day (15 cigarettes) Abut 1 pack per day (20 cigarettes) Mre than 1 pack per day D yu use any illegal drugs? Yes N If yes, what? D yu drink alchl? Yes N If yes, hw ften? /day /week /mnth /year Marital Status Single Married Separated Divrced Widwed Emplyment Status Unemplyed Emplyed Full Time Part Time If unemplyed right nw, indicate the last date wrked: / / If ut f wrk, what was yur reasn fr leaving? Due t pain prblem Nt due t pain
Please check any f the fllwing symptms r prblems that yu have experienced during the last six (6) mnths CONSTITUTIONAL: Weight gain Weight lss Marked fatigue Fever Chills/Sweats EYES: Blurred visin Duble visin Eye pain EARS, NOSE & THROAT: Lss f hearing Ringing in ears Sinus prblems ENDOCRINE: Excessive thirst Cld intlerance Heat intlerance RESPIRATORY: Persistent cugh Cughing up bld Wheezing CARDIOVASCULAR: Chest pain/ pressure/ tightness Heart Palpitatins Rapid f Irregular heart rate Lw bld pressure High bld pressure Shrtness f breath Pr circulatin GASTROINTESTINAL: Persistent/recurring stmach pain Diarrhea Cnstipatin Bld in stl Heartburn r indigestin Nausea/vmiting Yellwing f skin/jaundice HEMATOLOGY: Easy r frequent bruising Prlnged bleeding GENITOURINARY: Bld in urine Painful urinatin Urgency t urinate Frequent urinatin Difficulty urinating Lss f cntrl f bladder Lss f cntrl f bwel MUSCULOSKELETAL: Jint pain Jint stiffness Jint redness r swelling Leg cramps SKIN: Rash Nail r hair changes Hives Sres that dn t heal NEUROLOGICAL: Headaches Blackuts/Fainting Dizziness r Vertig Seizures Weakness Memry lss PSYCHIATRIC: Depressin r depressed md Anxiety Difficulty sleeping Please answer the fllwing questins: In the last 2 weeks have yu been bthered by little interest r pleasure in ding things? Yes N In the last 2 weeks have yu been feeling dwn, depressed r hpeless? Yes N Have yu had the Influenza (Flu) sht within the past year? Yes N If yes, when (apprximate date)? If yu are ver 65 years f age, have yu had a pneumnia sht? Yes N If yes, when (apprximate date)?
PAIN DIAGRAM Draw the lcatin f yur pain n the bdy utlines & mark hw severe it is n the pain line at the bttm f the page. Use a red pen if available. Aching Burning Numbness Pins & Needles Stabbing Other ^^^^ XXXX 000000 ***** ///// ^^^^ XXXX 000000 ***** /////. PAIN LINE Draw a perpendicular line r arrw t indicate yur usual level f pain. n pain 1 2 3 4 5 6 7 8 9 severe pain Patient Signature: Date:
Pain Disability Index In rder t determine hw effective yur treatment is, we need t knw hw much pain is interfering in yur nrmal activities. Please select the number n the scale which describes the level f disability yu have experienced in each area OVER THE PAST WEEK. A scre f "0" means n disability at all, and a scre f "10" indicates that all f the activities which yu wuld nrmally d have been ttally disrupted r prevented by yur pain ver the past week. Circle "0" if a categry des nt apply. FAMILY/HOME RESPONSIBILITIES: This categry includes chres r duties perfrmed arund the huse (e.g., yard wrk, huse cleaning) and errands r favrs fr ther family members (e.g., driving the children t schl). N Disability Mild Mderate Severe Ttal Disability RECREATION: This categry includes hbbies, sprts, and ther similar leisure time activities. N Disability Mild Mderate Severe Ttal Disability SOCIAL ACTIVITY: This categry refers t activities which invlve participatin with friends and acquaintances ther than family members. It includes parties, theater, cncerts, dining ut, and ther scial functins. N Disability Mild Mderate Severe Ttal Disability OCCUPATION: This categry refers t activities that are a part f r directly related t ne's jb. This includes nnpaying jbs as well, such as husewife r vlunteer wrker. N Disability Mild Mderate Severe Ttal Disability SEXUAL BEHAVIOR: This categry refers t the frequency and quality f ne's sex life. N Disability Mild Mderate Severe Ttal Disability SELF-CARE: This categry includes activities which invlve persnal maintenance and independent daily living (e.g., taking a shwer, driving, getting dressed). N Disability Mild Mderate Severe Ttal Disability LIFE-SUPPORT ACTIVITY: This categry refers t basic life-supprting behavirs such as eating and sleeping. N Disability Mild Mderate Severe Ttal Disability Office Use Scring: Sum Ttal: /70