Dr. Moore’s New Patient Questionnaire
Name:
Age:
Date:
What problem would like evaluated today (e.g. left knee pain)? ______________________
____________________________________________________________________________
On the body diagrams use the appropriate symbols to mark where you feel the following sensations:
Numbness
===
Pins and Needles
ooo
Burning
xxx
Stabbing
///
Aching
•••
On the line below please indicate (with an X) how severe your pain is now.
No Pain-----------------------------------------------------------------------------Worst possible pain
0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 – 10
When did the problem start (approximately what date)?
Did the problem result from trauma (e.g. an accident)?
 yes
 no
If yes, please describe: ___________________________________________________
Have you been evaluated by a physician or received any treatment for this problem?
 yes  no
If yes, what treatments (check all applicable boxes)?
 Pain medicine
 Brace
 Physical Therapy
 Surgery
 Injections
 Alternative Medicine
 Other___________
If you have pain, what is it like (check all applicable boxes)?
 Sharp
 Dull
 Ache
 Episodic
 Constant
 Numb
 Burning
 Radiating
 Stiffness
 Swelling
 Joint feels unstable
 Other_________________________________________
Patient:
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What makes your symptoms worsen?
 Motion
 Activity
 Bending
 Lifting
 Running
 Touch
 Standing
 Lying
 Sports
 Random
 Overhead activities
What makes your symptoms improve?
 Physical Therapy
 Ice
 Alternative Meds
 Injections
 Exercise
 Massage
 Heat
 Sitting
 Nothing
 Early morning
 End of day
 Other _________________
 Medicine
 Lying down
 Other_______________________
What is your height (in feet and inches)? __________
What is your weight (in pounds)?
__________
Past Medical History: Please check (X) the box next to any problems that apply to you (or the patient if
completing for a child).
 Heart disease
 Lung disease
 Kidney disease
 Eye disease
 Auto-immune disease  High blood pressure
 Liver Disease/Hepatitis  Diabetes
 Thyroid Disease
 Other endocrine disease  Ulcers/Reflux
 Neurological disease
 Stroke
 Epilepsy
 Skin lesions or rash
 Bleeding/Easy bruising  Sickle cell disease
 Other anemia
 Cancer
 Arthritis
 Gout or pseudogout
 Depression
 Other psychiatric disease
 None
 Other__________________________
Past Surgical History: Please list all surgeries you have had, their dates, and the hospital where the
procedure was done.
 None
Type of Surgery
Date of Surgery
Name of Hospital
Have you had any of the following diagnostic studies performed?
 X-rays / radiographs
 CT (computed tomography)
 MRI (magnetic resonance imaging)
 EMG/NCV (electromyogram / nerve conduction velocity)
 Bone scan / nuclear medicine study
Who is your primary care doctor or provider?________________________________
Medications:
What medications do you take? ______________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Patient:
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Allergies: Please check (X) the box next to any allergies that apply to you.
 No Known Allergies
 Penicillin
 Sulfa
 Iodine
 Shellfish
 Cephalosporins
 Other antibiotics, medications, foods, or dyes:_________________________________
Do you have any difficulty taking anti-inflammatory medicines (e.g. Motrin)?
 Yes  No
 Unknown
Review of Symptoms: Please check (X) the box next to any problems that apply to you (or the patient if
completing for a child).
 Fever or Chills
 Difficulty sleeping
 unintended weight loss
 Heat or Cold Intolerance
 Change in Gait
 Weakness
 Loss of control of bowel
 Loss of control of bladder
 Numb arm or leg
 Dizzy or light-headed
 Chest Pain
 Shortness of breath
 Night pain
 Endocrine/hormonal
 Psychiatric/emotional
Other difficulties:________________________________________________________
Family History:
 Cancer
 Bleeding Problems
 Other
 Diabetes
 Sickle cell anemia
 Heart Disease
 Sudden death
 Stroke
 Arthritis
Social History:
Tobacco use:
 no
 yes if yes, packs per day_____, years of use _____
Alcohol use:
 no
 yes if yes, amount per week_________.
Work status:
 employed
 unemployed
 disabled
 retired
What is your occupation?_________________________________________
Marital status:  single  married
 divorced
 separated
 widow/widower
Handedness:
 right  left  ambidextrous
Developmental History: (complete if patient is an infant or child)
Did pregnancy go to full term?
 yes  no
 unknown
Normal birth / normal first exam?
 yes  no
 unknown
Normal motor developmental milestones?  yes  no
 unknown
Normal verbal developmental milestones?  yes  no
 unknown
Are immunizations up to date?
 yes  no
 unknown
Is the child generally healthy?
 yes  no
 unknown
If you answered “no” to any of the above questions, please elaborate below:
________________________________________________________________
________________________________________________________________
Doctor’s Notes:
Patient:
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