Referring Physician/Therapist. Primary Care Physician. Reason for Visit

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Transcription:

Name Age Date Referring Physician/Therapist Primary Care Physician Reason for Visit If you are having pain, use the diagram and symbols to indicate where it is. Ache: AAA Burning:XXX Numbness:OOO Pins/Needles: Stabbing:///// Approximate Date Symptoms Started Describe how your symptoms started (i.e., describe how the injury occurred)

Describe your current symptoms What makes your symptoms better? What makes your symptoms worse? Briefly describe any treatment you have had thus far (Physicians, Chiropractors, Physical Therapists) Circle any of the following you have had for your symptoms: X-ray CT Scan MRI EMG/NCS Epidurals Please list any medications, natural supplements, and vitamins you taking: Medication Dose Frequency Medication Dose Frequency If more space is required, please use other side of page or attach medication list List any allergies you have, or medications you have had adverse reactions to, including contrast and shellfish allergy:

PAST MEDICAL HISTORY Anxiety Heart Attack Polio Thyroid trouble Depression Hypertension Asthma Heart Murmur Stroke High Cholesterol Alcoholism Liver disease Cancer Lung Disease Parkinson s Rheumatic Fever Hepatitis Chronic pain Diabetes Ulcers/PUD Arthritis Claustrophobia Other Have you ever had similar symptoms/injury before? No Yes If yes, when: Please describe briefly: Have you ever been diagnosed with fibromyalgia or chronic fatigue syndrome? PAST SURGICAL HISTORY Have you had any surgeries? No Yes If yes, please list type of surgery and approximate date: 1. 2. 3. 4. 5. 6. FAMILY HISTORY Please check box for any medical condition that a blood relative has a history of: Anxiety Heart Attack Polio Thyroid trouble Depression Hypertension Asthma Heart Murmur Stroke High Cholesterol Alcoholism Liver disease Cancer Lung Disease Parkinson s Rheumatic Fever Hepatitis Chronic pain Diabetes Ulcers/PUD Arthritis Claustrophobia Psychiatric illness Other SOCIAL HISTORY Marital Status: (Check one or more) Single Married Divorced Widowed Living together Separated

Number of children: Ages: Do you smoke? No Yes How much? Previous Smoker? No Yes When stopped? Do you drink alcohol? No Yes How much? Coffee, tea, cola beverages (cups/glasses/cans per day) Do you use recreational drugs? Are you currently employed? No No Yes What type/how often? Yes If yes, type of job If you exercise regularly, what types of activities/sports do you enjoy? REVIEW OF SYSTEMS Please mark those items which you currently experience: GENERAL Fever Weight gain Weight loss Fatigue Chills Weakness Night sweats DERMATOLOGIC Jaundice Itching/rash Lesions Easy bruising HEAD/HEARING & VISION Trauma Headaches Tenderness Dizziness Ringing in ears Blindness Blurred vision Changes/loss Discharge Rings around lights Double vision Light sensitivity Glasses PULMONARY Wheezing Shortness of breath Chronic cough Coughing up blood CARDIOVASCULAR Chest pain Leg swelling Shortness of breath with exertion Racing heart GASTROINTESTINAL Nausea Abdominal pain Bloody stool Constipation Diarrhea Vomiting Stool color changes Heartburn Incontinence of bowels

GENITOURINARY Blood in urine Vaginal discharge Pregnancy Pain/burning on urination Incontinence Venereal disease Sexual problem Painful menstruation Menopause Urgency/frequency with urination Irregular menstruation MUSCULOSKELETAL Arthritis Joint swelling Trauma NEUROLOGICAL Loss of Sensation Seizures Numbness and Tingling PSYCHOLOGICAL Sadness Anxiety Depression

(OPTIONAL) Please check any of the following statement if it something you have said or might say: I don t really like doctors. I try to stay away from them as much as possible. I have been everywhere, and no one seems to understand me or my pain. I read about everything on the internet. I have read all about my condition. The only thing that seems to help me is pain medication. I prefer my doctor to make the plan of care for me. I will basically do what he or she wants. I prefer to avoid surgery if I can. Find it, fix it. However aggressive you need to be. I don t like taking medications. I only take natural products.

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