Ken Pettine, MD
Tom Coburn, MD
Russell Parker, DO
NAME: _____________________________
D.O.B: ______________DATE: __________________
PATIENT QUESTIONAIRE
CHIEF COMPLAINT: (Circle all that apply): Headache, Neck Pain, Shoulder/Arm Pain, Other
Low Back Pain, Buttock Pain Leg Pain, Other
(Describe): List in order of severity:
1) _________________________________
3) ________________________________
2) _________________________________
4) ________________________________
Is your overall problem:
Getting better Getting worse or
Staying the same
How did your pain begin: Unknown Auto Accident Trauma or Other cause
(Describe)__________________________________________________________________________________
__________________________________________________________________________________________
Current Height: ____________________________
Current Weight: ____________________________
When did your pain begin? Date ______________________________________
List all Medicines used for: Headache, Neck pain, Shoulder/Arm pain
Over the counter: _________________________________ Prescribed_________________________________
List all Medicines used for: Low Back Pain, Buttock Pain Leg Pain, Other
Over the counter: _________________________________ Prescribed_________________________________
Where do you have pain? Mark on the pictures with the symbols:
01/2014
BURNING
XXXXX
ACHING
VVVVV
STABBING
///////
PINS & NEEDLES
………..
NUMBNESS
NNNNN
What is the current diagnosis: Circle all that apply
Headache/Neck Pain:
Cervical Strain Migraine Herniated Disc Thoracic Pain
No Diagnosis
Back Pain:
Lumbar Strain Herniated Disc Sciatica Sacroiliac Problem
No Diagnosis
Joint Pain:
Hip
Knee Ankle Foot Shoulder
Elbow Wrist Hand No Diagnosis
Other: ________________________________________________________________________
What makes your pain Better? ____________________________________________________
What makes your pain Worse? ____________________________________________________
Is your pain worse on the: Neck: LEFT
RIGHT
BOTH
Back: LEFT
RIGHT
BOTH
Typically, how severe is your pain? Rate your pain in a scale of 1-10 and place a number in each of the blank
spaces:
NO
0
1
3
4
5
6
7
8
9
10 WORST PAIN
PAIN__________________________________________________________ I CAN IMAGINE
Neck:_____Headache:_____ Thoracic: _____Arm: R _____ L _____ Shoulder: R _____ L _____ Elbow: R_____ L_____ Wrist/Hand: R_____ L: _____
Are your symptoms severe enough that you would consider surgery? YES
NO
NO
0
1
3
4
5
6
7
8
9
10 WORST PAIN
PAIN__________________________________________________________ I CAN IMAGINE
Low Back: _____ Buttocks: R _____ L ______ Hip: R _____ L _____ Leg: R _____ L _____ Knee: R _____ L _____ Ankle/Foot: R_____ L_____
Are your symptoms severe enough that you would consider surgery? YES
NO
PREVIOUS TREATMENT
Physical Therapy:
Did this help:
YES
YES
NO
NO
Length of treatment: ____________________________________
Where: _______________________________________________
Chiropractic:
Did this help:
YES
YES
NO
NO
Length of treatment:_____________________________________
Where: _______________________________________________
Massage:
Did this help:
YES
YES
NO
NO
Length of treatment: ____________________________________
Where: _______________________________________________
Other Treatment:
YES
Describe treatment:
Did this help
YES
NO
Length of treatment: ____________________________________
______________________________________________________
Where: _______________________________________________
NO
List the previous Medical Doctors you have seen for condition/Pain
MD: __________________________ MD: ________________________ MD: _________________________
Injury:_________________________ Injury: ______________________ Injury: _______________________
01/2014
IMAGING STUDIES PERFORMED:
Plain X-rays
CT Scan
MRI Scan
Myelogram
Injections
Discogram
Other
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
DATE
__________
__________
__________
__________
__________
__________
__________
WHERE
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
If Other: Describe: __________________________________________________________________________
PATIENT WITH HEADACHES, COMPLETE THE FOLLOWING:
Does you headache throb or pound: YES
NO
Do you feel a headache “coming on” or experience an “aura” (warning signs): YES
NO
Do you have any other symptoms accompanying your headache (circle all that apply)
Numbness
Tingling
Dizziness
Visual Problems
Nausea
Vomitting
Other: ________________________________________________________________________
How often do you have headaches: _____/week
How long does it last: _____hours
IF YOUR PROBLEM WAS CAUSED BY A WORK INJURY, COMPLETE SECTION C.
IF YOUR PROBLEM WAS CAUSED BY AN AUTO ACCIDENT, COMPLETE SECTION D.
SECTION C: (WORK INJURY)
Date and Time of Injury: ______________________________________________________________________
Describe your injury in detail: _________________________________________________________________
__________________________________________________________________________________________
Did you file an incident report:
YES
NO
How long were you employed before your work injury: _____________________________________________
Any history of previous symptoms or injuries:
YES
NO
If yes, please explain: ________________________________________________________________________
Any history of previous missed work due to injury: YES
Are you working now:
YES
NO
NO
When was the last time you worked full time: _________________
01/2014
Part time: _____________________
C. (CONTINUED)
Do you have any current work restrictions: YES
NO
If yes, please explain: ________________________________________________________________________
Detail your job description: ___________________________________________________________________
Total time lost from work: ____________________________________________________________________
Do you have a lawyer working on this claim:
YES
NO
If yes, Name and contact information of lawyer: __________________________________________________
SECTION D: (AUTO ACCIDENT INJURY)
Are you working now:
YES
NO
When was the last time you worked full time: _______________________ Part Time: ____________________
Total time lost from work: ____________________________________________________________________
Do you have any current work restrictions: YES
NO
If yes, please explain: ________________________________________________________________________
Date and time of accident: ____________________________________________________________________
Location of accident: ________________________________________________________________________
Make and model of car: ________________________________ Amount of damage _____________________
Other passengers injured in your car: ___________________________________________________________
Your position in the car: __________________________________ Seat belt worn: YES
NO
How accident occurred: ______________________________________________________________________
Initial treatment at: _________________________________________________________________________
Did you lose consciousness: YES
NO
Transported by:
Ambulance
private vehicle
Where X-Rays taken:
YES
NO
If yes, which ones: __________________________________________________________________________
Type of treatment: __________________________________________________________________________
Location and type of pain: ____________________________________________________________________
Did you consult your PCP after the accident:
YES
NO
Do you have a lawyer working on this claim:
YES
NO
If yes, Name and contact information of lawyer: __________________________________________________
01/2014
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