HISTORY PAPERWORK FOR APPOINTMENTS WITH DAVID A. PROPST, D.O. Name: Age: Room Number: Sex: MALE or FEMALE Dominant Hand: RIGHT or LEFT Height Weight Blood pressure HISTORY 1. Did your first symptoms begin after an injury? YES NO Date and place of injury: Activity which lead to injury? 2. Did the injury occur at work or is it work related? YES NO Employers Name: Employers Address: Employers Phone Number: 3. Did you have spinal problems or pain before this injury? YES NO Describe: 4. Did your FIRST symptom begin without an injury? YES NO If yes, on what date? 5. Do you recall any activity which prompted the onset of your pain? YES NO Describe: CURRENT SYMPTOMS 1. Do you have pain? YES NO Name all areas of your body where pain exists: Which one area is worse: 2. Do you have weakness? YES NO 3. Do you have numbness? YES NO 4. Do you have tingling, pins and needles, or other uncomfortable sensations? YES NO 5. Do you have clumsiness when you walk? YES NO 6. Do you have clumsiness when you run? YES NO 7. Do you have clumsiness when you use your hands/fingers? YES NO 8. Do you have problems with balance? YES NO 9. Do you have problems with or recent changes in bowel habits? YES NO 10. Do you have problems with or recent changes in bladder habits? YES NO 11. Do you have sexual difficulties? YES NO 12. Do your symptoms cause you to be depressed? YES NO 13. Do your symptoms cause insomnia or difficulty sleeping? YES NO
CURRENT TREATMENTS 1. MEDICINE YES NO Narcotic Pain Medicine? YES NO Muscle Relaxants? YES NO Sleeping Pills? YES NO Anti-Inflammatory Medicine? YES NO Steroid Medicine? YES NO Blood Thinners? YES NO 2. PHYSICAL THERAPY YES NO Prescribed by whom: How many visits per week? How many weeks? Active Exercise YES NO Modalities (Heat/Ice) YES NO Stretching YES NO TENS Unit YES NO Back School YES NO Home Exercise Program YES NO Pool Therapy YES NO Manual Therapy YES NO 3. ORTHOTIC YES NO Soft Neck Collar YES NO Soft Corset YES NO Hard Neck Collar YES NO Hard Brace YES NO 4. PAIN MANAGEMENT YES NO Outpatient? YES NO Inpatient? YES NO Name of Facility: Phone: Dates of treatment: Name of Facility: Phone: Dates of treatment: 5. INJECTIONS YES NO Neck Injections (i.e. Epidural steroids, facet blocks) YES NO If yes, how many times? Did they provide relief? YES NO If yes, for how long did they provide relief? 6. CHIROPRACTIC TREATMENTS YES NO Name of Chiropractor: Phone Number:
CURRENT WORK STATUS 1. Are you currently working? YES NO If YES: Are you working: Fulltime or Part Time Are you working: Full Duty or Modified Duty If NO: How long have you been off? Reason for off work status: 2. Is your appointment today covered by a Worker s Comp Claim YES NO If YES, please advise the front desk when you turn in this paperwork. ALLERGIES 1. Do you have allergies? YES NO If YES, Please list your allergies: SURGICAL/HOSPITALIZATION HISTORY 1. Have you previously had NECK or BACK surgery? YES NO Operation Date Surgeon Hospital Location 2. Have you had previous surgeries on other areas? (i.e. gallbladder, tonsils, appendix, orthopedic surgeries) YES NO Operation Date Surgeon Hospital 3. Have you ever been hospitalized due to surgery or for any other reason? YES NO Reason Date Surgeon Hospital 4. Have you ever had a problem with anesthesia? YES NO 5. Has anyone in your family ever had a problem with anesthesia? YES NO 6. Have you ever had a problem during or after surgery? YES NO 7. Have you ever had bleeding complications during or after surgery or a dental procedure? YES NO FAMILY HISTORY Age if living Medical Conditions Deceased Age at Death Cause of Death Father YES NO Mother YES NO SOCIAL HISTORY
1. Marital Status: ( ) Married ( ) Single ( ) Divorced ( ) Separated ( ) Widowed 2. Do you drink caffeine? YES NO If yes, how much: 3. Do you use recreational drugs? YES NO 4. Do you drink alcohol? YES NO If yes: ( ) Beer ( ) Wine ( ) Liquor ( ) Other: How often: ( ) Daily ( ) 1-2 week ( ) 1-2 month ( ) 1-2 year ( ) rarely ( ) socially 5. Do you smoke? YES NO If yes, how much: If you quit, when did you quit? 6. Do you exercise? YES NO If yes, how often: If No, is it because of your injury? YES NO 7. If you are a FEMALE age 50 and over and are postmenopausal, have you had a DEXA Scan in the last year? YES NO REVIEW OF SYSTEMS Constitutional Symptoms Musculoskeletal Chills YES NO Swelling in small joints of hands and feet YES NO Fever YES NO Pain in small joints of hands and feet YES NO Night/Day Sweats YES NO Swelling in large joints YES NO Weight Loss YES NO Pain in large joints YES NO Weight Gain YES NO Fractures YES NO Breast Morning stiffness YES NO Masses YES NO Great toe pain YES NO Nipple Discharge YES NO Muscle cramps YES NO Axillary Nodes YES NO Calf pain with walking YES NO Cardiovascular Muscle wasting YES NO Chest Tightness YES NO Urology Sleep with three or more pillows YES NO Urinary frequency YES NO Chest Pain YES NO Urinary urgency YES NO Leg swelling YES NO Inability to urinate YES NO Palpations YES NO Dribbling YES NO Shortness of breath YES NO Increase in amount of urine YES NO Respiratory Stones YES NO Pain with breathing YES NO Discharge YES NO Coughing blood YES NO Venereal disease YES NO Productive Cough YES NO Pelvic pain YES NO Cough YES NO Painful intercourse YES NO Wheezing YES NO Blood in urine YES NO Gastroenterology Neurology Swallowing difficulty YES NO Periods of unconsciousness YES NO Heartburn YES NO Temporary episodes of leg weakness YES NO Nausea YES NO Temporary episodes of arm weakness YES NO Vomiting YES NO Changes of smell YES NO Vomiting blood YES NO Changes in taste YES NO Black/Tarry Stools YES NO Gait disturbances YES NO Abdominal pain YES NO Blurred vision YES NO Jaundice YES NO Hearing loss YES NO Blood in stool YES NO Headaches YES NO Diarrhea YES NO Temporary episodes of blindness YES NO Loss of appetite YES NO Tremors YES NO
Constipation YES NO MEDICAL HISTORY Indicate ALL of your medical problems below Cancer: YES NO High Blood Pressure YES NO Heart Problems: YES NO Diabetes YES NO Bleeding Disorders: YES NO High Cholesterol YES NO Lung Problems: YES NO Anxiety/Depression YES NO Digestive Complications: YES NO AIDS/HIV YES NO