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ffice Use Arrival: Checked In: Roomed: ***PLEASE USE BLACK INK*** New Patient History Inventory Patient Name: Date of Birth: Age: What brings you to the office, and when was the date it started? Did your pain begin gradually or suddenly? Was there any trauma or any other inciting event that caused the pain? Is this a work related injury? (Required) Y N if yes, did you file a Worker s Comp Claim? Y N Are you still working? Y N If no, when was your last day of work? Are you on disability? Y N If yes, when did you go on disability? How bad is your pain now? (Circle NE) 0 1 2 3 4 5 6 7 8 9 10 No pain Excruciating pain Please mark the body diagram where you feel: Ache: Burning: XXXXXXXX Numbness: 0000000 Pins & Needles: //////// Stabbing: ==== Is your pain constant or does it vary based on your activity or position? How does the following affect your pain? Increases Decreases No effect

Sitting Standing Lying down Bending Lifting Walking Coughing/Sneezing Have you had treatment by the following for your neurosurgical problem (see below)? Yes No When? Result? Physical therapy Chiropractic Acupuncture Injections ther (specify) Do you have any weakness associated with your pain? Yes No Explain: Does your pain wake you up at night? Yes No verall, would you say you are (circle one): improving worsening about the same Medical History: Do you have any of the following medical conditions? Medical Y N Medical Y N Medical Y N Asthma/ Emphysema Hepatitis Parkinson s disease Tuberculosis Pacemaker Tremor CPD Heart Attack Stroke Cancer (list type): Hypertension Epilepsy/Seizures Atrial Fibrillation Multiple Sclerosis (MS) Depression High Cholesterol Peripheral Neuropathy Diabetes Congestive Heart Failure Arthritis Thyroid (Low/High) Irregular Heart Beat steo Arthritis steoporosis Murmur Rheumatoid Arthritis Kidney Problems Scoliosis Acid Reflux Disease Stomach Ulcers Carotid Disease Saroidosis Polio Blood/Bleeding Disease Fibromyalgia HIV Blood Clots/PE Chronic Fatigue Syndrome Previous Surgery (include dates) Previous Hospitalizations (include dates) Family History: Family History Age if Age at Present Condition or

Father Mother Brothers: Number: Sisters: Number: Children: Number: Living Death Cause of Death Check if any Relatives have had: Diabetes... Tuberculosis... Mental Illness. Heart Trouble... Thyroid Trouble. Suicide. Heart Attack.. Arthritis..... Melanoma. High Blood Pressure. besity (verweight) Aneurysm. Stroke. Cancer... Cancer Type: Social History: Marital Status (Please Circle ne): Single Married Divorced Widowed Separated ccupation (Job): Highest level of education completed: Smoking/Tobacco Use: Yes No Quit How many cig per day Pipe Cigar Chew If quit, years stopped How soon after you wake up do you smoke your first cigarette? Drink Alcohol: Yes per day per week (Circle) Beer / Wine / Liquor No Do you drink more than 6 drinks in one day? Yes No Problem with Alcohol? Yes No Recreational Drugs: Yes No If yes, list drugs: Medications & Supplements: Name of Medications Dosage Frequency 1. 2. 3. 4. 5. Allergies: Do you have any allergies to medications? Yes No (no known allergies to medications) If yes, Please list medication and reaction to the medication(s): Medication Reaction 1. 2. 3. Please check YES R N for symptoms you have RIGHT NW: CNSTITUTINAL Yes No RESPIRATRY Yes No NEURLGICAL Yes No

Weight Loss Cough Seizures Fatigue Coughing Blood Weakness/Paralysis Fever Wheezing Numbness EYES GASTRINTESTINAL Tremors Double Vision Heartburn Headache Glaucoma Nausea/Vomiting Memory Loss Cataracts Constipation Trouble Finding Words EAR, NSE, THRAT Difficulty Swallowing Balance Problems Difficulty Hearing Jaundice MUSCULSKELETAL Ringing in Ears Abdominal Pain Joint Pain/Swelling Dizziness Black Stools Stiffness Sinus Trouble GENITURINARY Muscle Pain CARDIVASCULAR Pain Urinating Back Pain Murmur Urinary Frequency Neck Pain V Chest Pain Nighttime Urination Shoulder Pain Palpitations Difficulty Urinating PSYCHIATRIC Fainting Spells History Kidney Stone Anxiety/Depression Shortness of Breath History STD Mood Swings Difficulty Lying Flat Abnormal Discharge Difficult Sleep Swelling Ankles/ther Blood in Urine ALLERGIC/IMMUNLGIC ENDCRINE FEMALE NLY Hay Fever/Asthma Loss of Hair Menopause Hives/Eczema Heat/Cold Intolerances Are Your Periods Regular? SKIN Change in Nails HEMATLGIC/LYMPH Rash Prolonged Bleeding Lesions How did you hear about us? (Circle all that apply): 1) Referral from my physician 2) Friend/relative 3) TV ad 4) nline ad 5) nline search 6) ther: Patient Signature: Provider Signature: swestry Disability Index Please mark the bubble next to the statement that applies to you: Section 1 Pain Intensity

I have no pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment. The pain is very severe at the moment. The pain is the worst imaginable at the moment. Pain prevents me from standing for more than 10 minutes. Pain prevents me from standing at all. Section 7 Sleeping Section 2 Personal Care (washing, dressing, etc.) I can look after myself normally without causing extra pain I can look after myself normally but it is very painful. It is painful to look after myself and I am slow and careful. I need some help but manage most of my personal care. I need help every day in most aspects of my personal care. I need help every day in most aspects of self-care. I do not get dressed, wash with difficulty, and stay in bed. Section 3 - Lifting I can lift heavy weights without extra pain. I can lift heavy weights but it gives extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (i.e. on a table). Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can lift only very light weights. I cannot lift or carry anything at all. Section 4 Walking Pain does not prevent me walking any distance. Pain prevents me walking more than 1mile. Pain prevents me walking more than ¼ of a mile. Pain prevents me walking more than 100 yards. I can only walk using a stick or crutches. I am in bed most of the time and have to crawl to the toilet. Section 5 Sitting I can sit in any chair as long as I like. I can sit in my favorite chair as long as I like. Pain prevents me from sitting for more than 1 Pain prevents me from sitting for more than ½ Pain prevents me from sitting for more than 10 minutes. Pain prevents me from sitting at all. My sleep is never disturbed by pain. My sleep is occasionally disturbed by pain. Because of pain, I have less than 6 hours sleep. Because of pain, I have less than 4 hours sleep. Because of pain, I have less than 2 hours sleep. Pain prevents me from sleeping at all. Section 8 Sex life (if applicable) My sex life is normal and causes no extra pain. My sex life is normal but causes some extra pain. My sex life is nearly normal but is very painful. My sex life is severely restricted by pain. My sex life is nearly absent because of pain. Pain prevents any sex life at all. Section 9 Social Life My social life is normal and causes me no extra pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, i.e. sports. Pain has restricted my social life and I do not go out as often. Pain has restricted social life to my home. I have no social life because of pain. Section 10 Traveling I can travel anywhere without pain. I can travel anywhere but it gives extra pain. Pain is bad but I manage journeys of over two hours. Pain restricts me to short necessary journeys less than 30 minutes. Pain prevents me from traveling except to receive treatment. Patient name: Today s date: Section 6 Standing I can stand as long as I want without extra pain. I can stand as long as I want but it gives me extra pain. Pain prevents me from standing more than 1 Pain prevents me from standing for more than ½ an

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