Dr. James Webb & Associates
6550 E 71st St, Suite 200 • Tulsa, OK 74133
918.260.9322 Phone • 918.794.8702 Fax
www.stoppaintulsa.com
Patient Name:
DOB:
Sex:
DRUG ALLERGIES: (Please list reaction as well, i.e. mild, moderate, severe)
Current Health Problems:
Previous Health Problems:
Date of last MRI:
Date of Last DEXA:
Location of last MRI:
Location of last DEXA:
HOSPITALIZATIONS
Year
Reason
DO YOU HAVE OR HAVE YOU HAD:
Heart Disease
YES
NO
Heart Attack
YES
NO
Aneurysm
YES
NO
Hypertension
YES
NO
Mental Disorder
YES
NO
Diabetes
YES
NO
Do you smoke/chew tobacco?
Do you drink alcohol?
Do you use drugs?
Do you exercise regularly
How many hours do you sleep at night?
Hospital Name
Bypass/Stents
Stroke
Alzheimer’s
Cancer
Hip Fracture
Celiac Disease
YES
YES
YES
YES
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
Stomach Surgery
Crohn’s Disease
Kidney Disease
Osteoporosis
Alcoholism
Drug Abuse
if so, how much/often?
if so, how much/often?
if so, how much/often?
if so, how much/often?
OSTEOPOROSIS
Do you take any of the following medications? If so, please specify:
Proton Pump Inhibitor (Nexium, Prilosec, etc)
Hormone Replacement Therapy
Muscle Relaxers
Antidepressant
For Women Only
Last Menstrual Period
Age of Menopause
NO
NO
NO
NO
NO
NO
Blood Thinner
Steroids
Difficulty with periods? YES NO
Date of Last Mammogram:
Do you take estrogen replacement?
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
Dr. James Webb & Associates
General
□ Weight loss or gain
□ Change in appetite
□ Fatigue
□ Fever or chills
□ Weakness
□ Trouble sleeping
Skin
□ Rashes
□ Ease of bruising
□ Ease of bleeding
□ Lumps
□ Itching/Dryness
□ Color changes
□ Hair and nail changes
Head/Neck
□ Headache
□ Head injury
□ Neck Pain
□ Swollen glands
Ears
□ Decreased hearing
□ Ringing in ears
□ Earache
□ Drainage
Eyes
□ Vision Loss/Changes
□ Glasses or contacts
□ Pain
□ Redness
□ Blurry or double vision
□ Flashing lights
□ Cataracts
Nose
□ Stuffiness
□ Discharge
□ Itching
□ Nosebleeds
□ Sinus pain
Cardiovascular
□ Chest pain or discomfort
□ Tightness
□ Palpitations
□ Shortness of breath w/activity
□ Difficulty breathing lying down
□ Swelling
□ Sudden awakening from sleep
with shortness of breath
Gastrointestinal
□ Swallowing difficulties
□ Heartburn
□ Change in appetite
□ Nausea
□ Change in bowel habits
□ Rectal bleeding
□ Constipation
□ Diarrhea
□Yellow eyes or skin
Urinary
□ Frequency
□ Urgency
□ Burning or pain
□ Blood in urine
□ Incontinence
□ Change in urinary strength
Mouth / Throat
□ Dry mouth
□ Sore throat
□ Hoarseness
□ Thrush
□ Pain
Respiratory
□ Cough
□ Sputum
□ Coughing up blood
□ Shortness of breath
□ Wheezing
6550 E 71st St, Suite 200 • Tulsa, OK 74133
918.260.9322 Phone • 918.794.8702 Fax
www.stoppaintulsa.com
Vascular
□ Calf pain with walking
□ Leg cramping
Musculoskeletal
□ Muscle or joint pain
□ Stiffness
□ Back pain
□ Neck pain
□ Redness of joints
□ Swelling of joints
□ Trauma
□ Muscle Weakness
□ Arthritis
Neurologic
□ Dizziness
□ Fainting
□ Seizures
□ Weakness
□ Numbness
□ Tingling
□ Tremor
Endocrine
□ Osteoporosis
□ Head or cold intolerance
□ Sweating
□ Frequent urination
□ Thirst
□ Thyroid Problems
□ Pancreatitis
Psychiatric
□ Nervousness/Anxiety
□ Stress
□ Depression
□ Memory loss
□ Concentration Problems
Dr. James Webb & Associates
6550 E 71st St, Suite 200 • Tulsa, OK 74133
918.260.9322 Phone • 918.794.8702 Fax
www.stoppaintulsa.com
PAIN QUESTIONNAIRE
Where is your pain?
How long have you had the pain?
How would you describe the pain (sharp, burning, dull, aching, pressure, electrical shocks, twitching, etc.)?
Where does the pain seem to begin?
Does the pain travel anywhere?
YES
NO
Please rate your pain on a scale of 1 to 10 with 1 being hardly any pain and 10 being the worse pain imaginable.
Current pain
/
At its worst in the last day
/
10
10
At its best over the last week
What treatments have you tried?
Heat
Ice/Cold
Over the Counter Medication
Prescription Medication
Topical (Icy Hot, Capsacin)
Physical Therapy
Chiropractor
Hydrotherapy
Acupuncture
Herbal Medicine/Supplements
TENS Unit
Vertebroplasty/Kyphoplasty
Epidural Steroid Injection
Trigger Point Injection
Facet Injection
Other pain injection
Spine Surgery
Spinal Cord Stimulator
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
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What medication have you tried?
Cymbalta
Lyrica
Ellavil (amitriptyline)
Narcotics (lortab, percocet)
Muscle Relaxers
Sleep Aids
Other Medications
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
If yes, specify dose, medication, result
If yes, specify dose, medication, result
If yes, specify dose, medication, result
If yes, specify dose, medication, result
If yes, specify dose, medication, result
If yes, specify dose, medication, result
If yes, specify dose, medication, result
Pain History
Have you every broken a bone as an adult?
Have you ever been in a car wreck?
Did you have pain as a child or teen?
Has a family member had a hip fracture?
Have you ever fallen from a height (ladder, etc)?
Do you have fibromyalgia?
Do you have migraines or chronic headaches?
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
/
10
Dr. James Webb & Associates
6550 E 71st St, Suite 200 • Tulsa, OK 74133
918.260.9322 Phone • 918.794.8702 Fax
www.stoppaintulsa.com
Family History
Father
Mother
Siblings
Children
Living
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

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


Deceased







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If deceased, please list cause:
Family history of:
Heart Disease
Hypertension
Diabetes
Mental Disorder
Breast Cancer
Kidney Disease
Yes






No

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



Who?
Yes
Stroke

Cancer

Alcoholism

Hip Fracture 
Osteoporosis 
Medication List
Name of Medication
Dosage / Frequency
No
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


Who?