2014 Ashley Oaks Circle Wesley Chapel, Fl 33544
813.999.3030ph
813.333.0450fx
Jose M. De La Torre, MD
Today’s Date _______________________________
Social Security # ________-_______-_______
Patient Name ___________________________________________________________DOB ___________________ Gender:  Male  Female
Address_______________________________________________________________________________________________________________
City ______________________________________________________ State ______________________Zip_____________________________
Home Phone # ____________________________ Cell # ________________________________ Other ________________________________
May we leave detailed messages at the above listed numbers?  Yes  No
Race
:
Caucasian
Ethnicity:
American
Language Spoken:
English
Black
Cuban
Spanish
American Indian
Asian
Indian
French
Italian
Asian
Greek
Hispanic
Other ________________
Bosnian
African American
Other ___________________
Portuguese
Chinese
Japanese
Other ________________
In Case of an Emergency please contact:
Name _________________________________________________ Relationship _____________________ Phone # _______________________
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Primary Ins. Co ____________________________ Policy # ____________________________
Group # ____________________________
Policy Holder ______________________________
Relationship _________________________
DOB ______________________________
2nd Ins. Co ________________________________
Policy # _____________________________ Group # ____________________________
Policy Holder ______________________________
Relationship __________________________ DOB _______________________________
 Auto Related Injury?
Auto Accident Carrier __________________________________________________________________________________________________
Claim # _______________________________
Adjuster Name & Phone # ____________________________________________________
Date of Accident ____________________________________________
State of Accident _____________________________________
 Workers’ Compensation Related Injury?
Workers’ Comp. Ins. Carrier ____________________________________________________________________________________________
Claim # _______________________________ Adjuster Name & Phone # ________________________________________________________
Date of Injury _______________________________ State of Injury ____________________________________________________________
2014 Ashley Oaks Circle Wesley Chapel, Fl 33544
813.999.3030ph
813.333.0450fx
Jose M. De La Torre, MD
Primary Care Physician ___________________________________________________________Phone ________________________________
Pharmacy Name__________________________________________________________________Phone _______________________________
Pharmacy Location_____________________________________________________________________________________________________
INSTRUCTIONS: Please complete the following questionnaire before you see the doctor. Circle the answers that best describe your
situation. You may select more than one answer per question. This information will help your doctor to more accurately understand
your condition(s) and develop an appropriate plan of treatment. A copy of this form will be included in your medical record.
PATIENT NAME: _________________________________________________________
DATE: _____________________
OCCUPATION: ___________________________
EMPLOYER: ___________________________________________________
WHOM MAY WE THANK FOR REFERRING YOU? ___________________________________________________________________
1. CHIEF COMPLAINT:
WHAT IS THE REASON FOR YOUR VISIT TODAY:____________________________________________________________
2.
AGE OF PATIENT: ___________
3.
WHAT ARE YOU BEING SEEN FOR?
A. HEADACHE
B. NECK PAIN
C. UPPER BACK PAIN
D. LOWER BACK PAIN
E. ARM PAIN
F. LEG PAIN
G. OTHER: _________________
MALE
FEMALE
DO YOU HAVE ANY:
A. WEAKNESS
B. NUMBNESS
C. TINGLING
IF SO, WHERE? ______________________
IF MORE THAN ONE OF THE ABOVE IS CHOSEN, WHICH IS THE MOST PROBLEMATIC? _____________________________
MARK THE LOCATION(S) OF YOUR PAIN ON THE FIGURE(S) BELOW:
2014 Ashley Oaks Circle Wesley Chapel, Fl 33544
813.999.3030ph
813.333.0450fx
Jose M. De La Torre, MD
FOR SYMPTOMS OF PAIN FILL THE AFFECTED AREAS WITH THE FOLLOWING PATTERN: XXXXXXXX
FOR SYMPTOMS OF NUMBNESS/TINGLING FILL THE AFFECTED AREAS WITH: OOOOOO
PHYSICIAN NOTES:
4.
WHICH TERM BEST DESCRIBES YOUR PAIN? CHARACTER/ Quality of pain: (Please check one box per line that describes
your pain in words and severity)
Sharp
Stabbing
Burning/ Hot
Shooting
Aching
none
none
none
none
none
mild
mild
mild
mild
mild
moderate
moderate
moderate
moderate
moderate
severe
severe
severe
severe
severe
5.
RATE YOUR PAIN INTENSITY BY CIRCLING THE NUMBER THAT BEST DESCRIBES YOUR PAIN RIGHT NOW:
NO PAIN 0
1
2
3
4
5
6
7
8
9
10 INTOLERABLE
6.
WHEN DID THE PROBLEM(S) FIRST START OR WHEN DID THE INJURY OCCUR? __________________________________
7.
DID THE PROBLEM START AS A RESULT OF:
A. NORMAL DAILY ACTIVITY
B. MOTOR VEHICLE ACCIDENT
C. SPORTS OR RECREATION
D. FALL
8.
E.
F.
G.
H.
JOB RELATED
CANCER
ILLNESS
OTHER: _______________________________________
HAVE YOU SEEN A DOCTOR IN THE PAST MONTH FOR THIS CONDITION?
YES
NO
IF YES, WHO/WHEN ________________________________________________________________________
2014 Ashley Oaks Circle Wesley Chapel, Fl 33544
813.999.3030ph
813.333.0450fx
Jose M. De La Torre, MD
9.
HAVE YOU BEEN SEEN BY A PAIN MANAGEMENT DOCTOR BEFORE? YES NO
IF YES, WHO/WHEN ________________________________________________________________________
10. WHAT TREATMENT(S) HAVE YOU ALREADY RECEIVED FOR THIS CONDITION? (CIRCLE ALL THAT APPLY)
A. MEDICATIONS (LIST IN TABLE BELOW)
B. PHYSICAL THERAPY: HOW MANY WEEKS? ________
WAS IT EFFECTIVE? YES NO
C. STEROID/CORTISONE/EPIDURAL INJECTIONS? (LIST IN TABLE ON NEXT PAGE)
D. CHIROPRACTIC CARE: DR. _________________________ WAS IT EFFECTIVE? YES NO
E. TENS UNIT: PRESCRIBED BY: _______________________ WAS IT EFFECTIVE? YES NO
F.
SURGERY TYPE: ___________________________ WHEN? ________________ DOCTOR? ___________________
TYPE: ___________________________ WHEN? ________________ DOCTOR? ___________________
TYPE: ___________________________ WHEN? ________________ DOCTOR? ___________________
11. INJURY HISTORY (IF YOU HAVE NOT HAD ANY TYPE OF INJURY, CHECK BOX AND SKIP TO #12. )
A. HAVE YOU HAD ANY AUTO INJURIES? YES NO IF YES, WHEN? ____________________________
AUTO CASE IS: OPEN CLOSED
B. HAVE YOU EVER HAD ANY SPORTS INJURIES? YES NO IF YES, WHEN? _____________________
C. HAVE YOU EVER BROKEN ANY BONES?
YES NO IF YES, WHEN? _________WHAT BONE? ______________
D. HAVE YOU EVER HAD A WORKER’S COMPENSATION CLAIM? YES NO
WORK COMP CASE IS: (CIRCLE ALL THAT APPLY): CURRENT
PAST
OPEN
CLOSED
SETTLED
E. HAVE YOU EVER BEEN DISABLED?
YES NO
ARE YOU CURRENTLY DISABLED?
YES NO IF YES, WHAT TYPE? SSD SSI
12. SINCE THE PAIN/CONDITION BEGAN, IT:
A.
B.
C.
D.
HAS IMPROVED
HAS WORSENED
HAS REMAINED THE SAME
COMES & GOES (FLUCTUATES)
13. WHAT AGGRAVATES THE PAIN?
A.
B.
C.
D.
E.
F.
WHAT TIME OF DAY IS THE PAIN MOST INTENSE?
WALKING
H. COUGING
STANDING
I. TEMPERATURE
SITTING
OTHER: _____________
LYING DOWN
BENDING
ACTIVITY IN GENERAL
A.
B.
C.
D.
WHEN GETTING UP IN THE MORNING
DURING THE DAYTIME
AT THE END OF THE DAY BEFORE BEDTIME
DURING THE NIGHT
WHAT MAKES THE PAIN BETTER?
A.
B.
C.
D.
E.
F.
WALKING
STANDING
SITTING
LYING DOWN
RESTING
MEDICATION
14. DOES THE PAIN AWAKEN YOU FROM SLEEP?
A. NEVER
B. OCCASIONALLY
C. FREQUENTLY
15. DO YOU HAVE ANY DIFFICULTY WALKING DUE TO THIS CONDITION?
A. YES
B. NO
16. HAVE YOU HAD ANY PROBLEMS WITH BOWEL, BLADDER, OR SEXUAL FUNCTIONS SINCE THIS CONDITION BEGAN?
A. NO
B. YES, EXPLAIN: ______________________________________________________________________
2014 Ashley Oaks Circle Wesley Chapel, Fl 33544
813.999.3030ph
813.333.0450fx
Jose M. De La Torre, MD
17. HAVE YOU HAD A PREVIOUS PAIN PROBLEM/CONDITION?
A. NO
B. YES, EXPLAIN:______________________________________________________________________
REVIEW OF SYSTEMS: HAVE YOU RECENTLY EXPERIENCED ANY OF THE FOLLOWING? (MARK YES OR NO FOR EACH
EYE, EAR, NOSE, THROAT
GENERAL
Y N
CARDIOVASCULAR
Y N
Y N
EYE PROBLEMS
DOUBLE VISIONS
HAY FEVER
LOSS OF HEARING
FEVERS
CHILLS
NIGHT SWEATS
MALAISE
DIZZINESS
WEIGHT GAIN
WEIGHT LOSS
LOSS OF SLEEP
MUSCLE/BONE/JOINTS
Y N
MUSCLE SPASM(S)
NECK PAIN
ARM PAIN
BACK PAIN
LEG PAIN
JOINT PAIN
PELVIC PAIN
GASTROINTESTINAL
Y N
CHEST PAIN
CONSTIPATION
BLOATING
DIARRHEA
RECTAL BLEEDING
HIGH BLOOD PRESSURE
RAPID HEARTBEAT
SWELLING OF ANKLES
POOR EXERCISE
ABILITY
SNORING
SINUS PROBLEMS
EARACHE
GENITO-URINARY
Y N
BLOOD IN URINE
FREQUENT URINATION
INCONTINENCE
PAINFUL URINATION
STOMACH BLEEDING
SKIN
STOMACH PAIN
CANCER
DISEASE
NAUSEA/VOMITING
HEARTBURN
NEUROLOGICAL
Y N
HEMATOLOGICAL
Y N
NERVE DAMAGE
SEIZURES (ACTIVE)
NUMBNESS/TINGLING
LIGHTHEADEDNESS
MUSCLE WEAKNESS
CANCER
PROSTATE/COLON
BREAST
PERSISTENT COUGH
COUGHING BLOOD
SUICIDAL IDEATION
BLEEDING PROBLEMS
BLEEDING GUMS
ADDICTION
NERVOUSNESS
CHRONIC BRONCHITIS
SLEEP APNEA
USE OXYGEN
USE CPAP
ENDOCRINE
AGGRENOX
PRADAXA
OTHER ______
LUNG
OTHER ________
RESPIRATORY
Y N
FEELING SAD/UNHAPPY
BLOOD DISORDER
DO YOU TAKE:
COUMADIN
LOVENOX
PLAVIX
HEPARIN
POOR CONCENTRATION
PSYCHIATRIC
Y N
SEVERE THIRST
SHORTNESS OF BREATH
SEVERE FATIGUE
TAKE CORTISONE
ALLERGY/IMMUNOLOGY
ROUGH SKIN/ELBOWS
DECREASED SEX DRIVE
SHELLFISH ALLERGY
LOSS OF SEXUAL
PERFORMANCE
HIV
ENVIRONMENTAL ALLERGIES
18. PAST SURGICAL HISTORY HAVE YOU HAD ANY SURGERIES? (INCLUDE PRIOR PAIN INECTIONS)
A. NONE
DATE
B. IF YES (LIST BELOW)
SURGERY
PHYSICIAN
19.PAST MEDICAL HISTORY
DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING MEDICAL CONDITIONS? (CIRCLE ALL THAT APPLY)
A.
B.
C.
D.
E.
F.
G.
H.
I.
NONE
THYROID DISORDER
OVERWEIGHT
LUNG DISEASE (COPD / EMPHYSEMA)
ASTHMA/TUBERCULOSIS
CORONARY ARTERY DISEASE (CHEST PAIN/ANGINA)
PRIOR HEART ATTACK if yes WHEN? _____________
HIGH BLOOD PRESSURE / HYPERTENSION
HEART DISEASE (CONGESTIVE HEART FAILURE)
J. HIGH CHOLESTEROL
K. PERIPHERAL VASCULAR DISEASE
L. STOMACH ULCERS
M. DIABETES MELLITUS
N. HEPATITIS, TYPE: ______
O. LIVER DISEASE
P. KIDNEY DISEASE
Q. IMMUNE DISORDER
R. SEIZURE DISORDER
S. MULTIPLE SCLEROSIS/ OR OTHER BRAIN DISEASE
T. STROKE / CVA
U. OSTEOARTHRITIS/ OSTEOPOROSIS
V. RHEUMATOID ARTHRITIS
W. ENDOMETRIOSIS/ OR PELVIC PAIN
X. DEPRESSION/ ANXIETY DISORDER
Y. MENTAL DISORDER(S)/ ______________________
Z. CANCER/TUMOR, TYPE: ______________________
*** LIST ALL OTHER: ___________________________
Jose M. De La Torre, MD
2014 Ashley Oaks Circle Wesley Chapel, Fl 33544
813.999.3030ph
813.333.0450fx
ALLERGIES
20. ARE YOU ALLERGIC TO ANY MEDICATIONS: ____ A. NO KNOWN ALLERGIES
____B. YES (LIST BELOW)
MEDICATION
REACTION (I.E. RASH, ETC)
CURRENT MEDICATIONS
21. ARE YOU CURRENTLY TAKING ANY MEDICATIONS: __A. NONE
__B. IF YES (LIST ALL BELOW)
MEDICATION
DOSAGE/FREQUENCY
PRESCRIBING PHYSICIAN
FOR WHICH CONDITION?
SOCIAL HISTORY
22. PLEASE ANSWER THE FOLLOWING ABOUT YOURSELF:
A. MARITAL STATUS:
SINGLE
MARRIED
DIVORCED
WIDOWED
B. WHO DO YOU LIVE WITH? ______________________________________________________________
C. YOUR HIGHEST LEVEL OF EDUCATION:
SOME HIGH SCHOOL
HIGH SCHOOL
TRADE SCHOOL
COLLEGE
D. DO YOU CURRENTLY WORK?
NO
YES: OCCUPATION ______________________ EMPLOYER: ________________
E. HOW MUCH ALCOHOL DO YOU CONSUME:
NONE
SOCIAL DRINKER
DRINK DAILY
RECOVERING ALCOHOLIC
F. DO YOU SMOKE?
NO
YES, I CURRENTLY SMOKE: ______# OF PACKS DAILY
I QUIT SMOKING ___YRS AGO
Have you been counseled about smoking cessation:
NO
YES
G. DO YOU HAVE A HISTORY OF USE/ABUSE OF ILLICIT DRUGS?
NO
YES: LIST: _______________________________
H. Have you ever taken a pill from a family member or from a friend?
NO
YES
FAMILY HISTORY
23. DO YOU HAVE A FAMILY HISTORY OF ANY OF THE FOLLOWING? (CIRCLE ALL THAT APPLY)
A. NONE
E. HEART DISEASE
I. OSTEOARTHRITIS
B. BACK/NECK PROBLEMS
F. HYPERTENSION
J. RHEUMATOID ARTHRITIS
C. CANCER
G. STROKE
K. BLEEDING DISORDERS
D. DIABETES
H. ASTHMA
L. LIST ALL OTHER: ________________________
Jose M. De La Torre, MD
2014 Ashley Oaks Circle Wesley Chapel, Fl 33544
813.999.3030ph
813.333.0450fx
24. PLEASE LIST THE NAMES OF ALL OF YOUR CURRENT PHYSICIANS:
PHYSICIAN
SPECIALTY
CERTIFICATION
 TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS COMPLETE AND CORRECT. I UNDERSTAND
THAT IT IS MY RESPONSIBILITY TO INFORM MY DOCTOR IF I, OR MY MINOR CHILD, EVER HAVE A CHANGE IN
HEALTH INFORMATION.
 I UNDERSTAND THAT I AM RESPONSIBLE FOR MY BILL AND AGREE TO PAY ALL CHARGES FOR SERVICES AND
ITEMS PROVIDED TO ME.
 I PERMIT A COPY OF THIS TO BE USED IN PLACE OF THE ORIGINAL.
__________________________________________________________________________
SIGNATURE OF BENEFICIARY, GUARDIAN, OR PERSONAL REPRESENTATIVE
_________________________
DATE
__________________________________________________________________________
PLEASE PRINT NAME OF PATIENT, PARENT, OR GUARDIAN
_________________________
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