Name: ___________________________________________ Date:_____________________ SS#: ____________________________
Height: _______________________________
Weight: _______________________________
History of Present Illness
Please explain your problem in one sentence:________________________________________________________________________
Where is your problem located?
Severity of pain. Scale of 1-10 1 - Minimal 10 - Severe _________________
Does the condition affect ability to work? Yes No ___________________________________
Medical Leave
Full Duty
Did you improve?_ _____________________________________________________________________________________________
_ ___________________________________________________________________________________________________________
Work related? Yes No
Right Left Location_____________________________________________________________
When did your problem start?_____________________________________________________________________________________
What else do you experience? Swelling Grinding Give way Catching Popping Locking Sleeping Problems
Occupation
Light Duty
How? _________________________________________________ Have you previously had this or a similar problem? Yes No
Why?________________________________________________________________________________________________________
What previous treatment for this problem have you had? Surgery_______________________________________________________
PT/OT Injections Casting Chiropractor
Braces / Straps Medicine_ _________________________________________________
Please list doctors who have treated you for this particular problem:
_______________________________________________________________________________________________________________
(Name) (Specialty) (City) (Date)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Have you had: X-Ray Bone Scan When Where Study Here MRI CT Report Here
Patient Medical History
Please circle Yes or No if you have any of the following medical problems.
High blood pressure Yes No Diabetes Yes No Heart Trouble Yes Bleeding Problems Yes No HIV / AIDS Yes No Other Problems _________________
Respiratory Problems Yes No Stroke Yes No Cancer Yes No
No
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Current Medications: _____________________________________________ ______________________________________________
_____________________________________________ ______________________________________________
_____________________________________________ ______________________________________________
Drug Allergies or Substance Allergies Yes No List:____________________________________________________________________
Past Hospitalizations / Surgeries / Injuries and Approximate Dates
_ ___________________________________________________
___________________________________________________
_ ___________________________________________________
___________________________________________________
_ ___________________________________________________
___________________________________________________
Family History: Have any of your relatives (e.g.. - Mother, Father, Brother, Sister, Grandparent) ever had:
1. Heart Disease 2. High Blood Pressure 3. Diabetes 4. Stroke 5. Cancer (Location) 6. Thyroid Disease 7. Other Disease Yes ____ ____ ____ ____ ____ ____ ____ No
____
____
____
____
____
____
____
Relationship
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
Social History: Marital Status: Single Married Separated Divorced Widowed
Alcohol Use: Never Rarely Moderate Daily How much? _______
Occupation: Tobacco Use: Drug Use: Never Never Quit/ When ___________ __________________ Current smoker / packs per day __________
Type & Frequency ________________________________
Other: ___________________________________________
Review of Systems (ROS)
Please circle Yes or No if you have any of the following problems.
Constitutional Good General Health Recent Weight Change Night sweats, fevers Fatigue Yes Yes Yes Yes No No No No
Ears/Nose/Mouth/Throat Hearing loss or ringing Sinus Problems Nose Bleeds Sore throat/voice change Yes Yes Yes Yes No No No No Eyes
Wear glasses/contacts Blurred/double vision Eye disease or injury Glaucoma Yes Yes Yes Yes No
No
No
No
Cardiovascular Chest pain Palpitations Heart Trouble Swelling hands / feet Yes Yes Yes Yes No No No No Respiratory Shortness of breath Cough Wheezing / Asthma Coughing up blood Yes Yes Yes Yes No No No No Gastrointestinal
Nausea / vomiting Abdominal pain Rectal Bleeding Bowel problems Yes Yes Yes Yes No
No
No
No
Musculoskeletal Muscle pain or cramps Stiffness/swelling joints Joint pain Trouble walking Yes Yes Yes Yes No No No No Neurological Frequent Headaches Paralysis or tremors Convulsions/seizures Numbness/tingling Yes Yes Yes Yes No No No No Integumentary (Skin / Breast)
Change in hair or nails Yes Rashes or itching Yes Breast lump Yes Breast pain or discharge Yes No
No
No
No
Endocrine Excessive thirst/urination Thyroid disease Hormone Problem Yes Yes Yes No No No Hematologic / Lymphatic
Bruise easily Slow to heal Enlarged Glands No No No No Genitourinary - Female Only Blood in urine Yes Kidney Stones Yes Sexual problems Yes Menstrual problems Yes Genitourinary - Male Only Blood in urine Yes Kidney Stones Yes Sexual problems Yes Testicle pain Yes Yes Yes Yes Allergic / Immunologic
No Food Allergies No Aspirin Allergies No Antibiotic Allergies No No No No
Yes No
Yes No
Yes No
Psychiatric
Insomnia Yes No
Confusion/memory loss Yes No
Depression Yes No
Patient Statement: To the best of my knowledge, the above information is accurate and complete.
Signed: _________________________________________ Date: _________________
Physician Statement: I have reviewed the questionnaire with the patient.
Signed: _________________________________________ Date: _________________