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Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Location Does the pain radiate anywhere ( shooting down or shooting up ) When was the pain started? How was the pain started? Work related Auto accident Athletic injury Injury at home Other

Please, describe your pain Dull Aching Sharp Shooting Stabbing Throbbing Numbness Burning How often is your pain present? Occasional Frequent Constant Worst time of day? Morning Afternoon Evening Night All the time Any color change or temperature change? Numbness anywhere? Pins and needles? Weakness? (Right leg, right arm, both legs.) Swelling? What makes symptoms worse/exacerbate? Walking Standing Lying down Sitting Bending forward Bending backward Driving Coughing Bowel movement Cold weather Hot weather Rainy day Lifting objects What makes the symptoms better? Resting Massage Exercise Sitting Lying down TENS unit Physical therapy Injections Sleeping Medication (Names) Other Sleeping : Well OK Terrible 2 hrs 4 hrs 6 hrs 8 hrs>10 hrs How often do you wake up at night? 0 1 2 3 4 >5 times Physical therapy Location Date of Last PT Duration TENS Unit Never used I have a unit I don t have one Used at home daily Used at home as needed Used during PT Previous injections Epidural Facet _ Nerve block Joints Others Acupuncture Psychotherapy Chiropractor Other (Biofeedback, Meditation, Yoga, Swimming)

Review of System Gen Weight loss Weight gain Fever Fatigue Loss of appetite Nausea Vomiting Skin Skin problem Rash Psoriasis Slow healing Easy bruising Itching Neuro Light headed/dizziness Fainting Weakness Stroke Tremor Seizure Memory loss Eyes Vision problem Glaucoma Blurred vision Double vision ENT Ear pain Hearing loss Ear noises Nose bleed Sore throat Hoarseness Dental problems Cardiovascular Chest pain Chest pressure Shortness of breath Irregular heart beat Murmurs Respiratory Coughing Difficulty breathing Asthma/Wheezing Coughing up blood Gastrointestinal Constipation Diarrhea Heartburn Bloody stool Pain in stomach Ulcers Hepatitis Genitourinary Painful urination Frequent urination Bloody urine Kidney stone Incontinence Loss of libido Sexual difficulty Infection Endocrine Hypothyroidism Hyperthyroidism Diabetes Parathyroid problems Hematology Anemia Bleeding disorder Easy bleeding Lymphoma/Leukemia Sickle cell disease Immunologic Catch cold easily HIV/AIDS Fever Hay fever Frequent sinus problems Allergies Neck injury Musculoskeletal Arthritis Rheumatoid arthritis Osteoarthritis Compression fracture Head injury Lower back injury Spinal trauma Birth trauma Birth defect LupusSpina bifida Gout Osteoporosis Muscular dystrophy Muscle pain Scoliosis Women only Irregular periods Premenstrual depression Hot flashes Menstrual cramps Vaginal discharge Hysterectomy Breast surgery Nipple discharge Breast lumps Last mammogram Men only Psychiatric Past Medical History Burning on urination Dripping after urination Prostate problems Difficulty starting urination Depression Anxiety Panic attacks OCD Manic Bipolar Suicidal attempts Suicidal ideation Homicidal Hallucination Psychosis Other Heart Coronary artery disease Hypertension Murmurs Valvular disease Aneurysm High cholesterol Pacemaker Deliberator Heart failure Angina Other Lungs Asthma COPD Emphysema Bronchitis TB Pneumonia Lung cancer Other Gastrointestinal Ulcer Reflux Gastritis Hepatitis Cancer Bleeding Diverticulosis Other Kidney Failure Stones Dialysis (When) Other Endocrine Diabetes Hypothyrodism Hyperthyroidism Other Neuro Stroke Aneurysm Brain cancer Nerve injury Spinal cord injury Alzheimer s Dementia Seizures Parkinson s Other Psychiatric Depression Bipolar Anxiety Panic disorder Psychosis Schizophrenia Other Bone/Muscular Arthritis Rheumatoid arthritis Osteoarthritis Gout Osteoporosis Scoliosis Other Cancer Other Past Surgery History Allergies Latex No Yes Reaction Contrast (Dye) No Yes Reaction Allergic to any medication(s)?

Current Medications _ Significant Family History (Cancer, hypertension, diabetes, depression, back pain ) Father side Mother side Siblings Social History Tobacco: Never Quit in Currently pack per day Alcohol : Never Rarely Moderate Daily Use of drugs: Never Occasionally Frequently, Type/frequency Marital status: Single Married Separated Divorced Widowed Family status: Living with Occupation: Disability: No Yes (Type) Litigation (Lawsuit): No Yes against working with Radiological studies / Lab studies MRI Neck Upper back Lower back Other Date Date Date Date CT Neck Upper back Lower back Other Date Date Date Date EMG Arm Leg Other

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