Section I - Patient Information Patient Name Patient Email Date of Birth Age Gender MaleFemale Approximately when did this pain begin Is your pain the result of a: Please Select OneWork Comp InjuryAuto InjuryPersonal Injury Are you involved in litigation regarding this pain? Please Select OneYesNo Have you ever been on disability? Please Select OneYesNo Are you working now? Please Select OneYesNo Last date of work? What kind of work do you do? Check all of the following that best describes your pain: Aching Hot/Burning Shooting Stabbing/Sharp Cramping Numbness Spasming Throbbing Dull Shock-Like Squeezing Tiring/Exhausting Tingling/Ping and Needles Other What word best describes the frequency of your pain? Please Select OneConstantIntermittent When is your pain at its worst? Mornings During the day Evening Middle of the night Other How long can you walk until you must stop due to pain? What activities is the pain preventing you from doing? My Pain is improved by Sitting Standing Lying Down Bending forward Extension (bending back) List Doctors you have seen & City: From 0-10 what best describes your pain right now? 0123456789010 From 0-10 what best describes your pain most of the time? 0123456789010 From 0-10 what best describes your worst pain? 0123456789010 From 0-10 what best describes your least pain? 0123456789010 Mark all of these diagnostic tests you have had related to your current pain complaints. MRI of the Date: Facility: X-Ray of the Date: Facility: CT-Scan of the Date: Facility: EMG / NCV of the Date: Facility: Other diagnostic testing Mark all of the following pain treatments you have undergone prior to today’s visit: Chiropractic Physical Therapy Massage Acupuncture Spine Surgery Psychological Therapy Spasming Discogram –(Circle all levels that apply) Cervical Thoracic Lumbar Epidural Steriod Injection –(Circle all levels that apply) Cervical Thoracic Lumbar Joint Injections – Joint(s) Medical Branch Blocks or Facet Injections –(Circle all levels that apply) Thoracic Lumbar Joint Injections – Joint(s) Radiofrequency Ablation –(Circle all levels that apply) Thoracic Lumbar Joint Injections – Joint(s) Spinal Stimulator - (Circle one)" "Trial Only" "Permanent Implant Trigger Point Injection – Where? Vertebroplasty / Kyphoplasty – Level(s)? Other Section II - Past Medical History Heart Murmur Please select oneYesNo Shortness of breath Please select oneYesNo Gastritis or ulcers Please select oneYesNo Palpitations Please select oneYesNo Bronchitis Please select oneYesNo Hital Hernia Please select oneYesNo Heart Attack Please select oneYesNo TB Please select oneYesNo Thyroid Disease Please select oneYesNo Stroke Please select oneYesNo Asthma Please select oneYesNo Diabetes Please select oneYesNo Irregular Heart Beat Please select oneYesNo Emphysema Please select oneYesNo Kidney Problems Please select oneYesNo High Blood Pressure Please select oneYesNo Sleep Disturbance Please select oneYesNo Liver Disease Please select oneYesNo Angina (Chest Pain) Please select oneYesNo Sleep Apnea Please select oneYesNo Difficulty Urinating Please select oneYesNo Seizures Please select oneYesNo Migraine Headaches Please select oneYesNo Hepatitis Please select oneYesNo Arthritis Please select oneYesNo Weight Change Please select oneYesNo HIV or exposure Please select oneYesNo Cancer Please select oneYesNo Other Section III - PAST SURGICAL HISTORY Name: Date: Name: Date: Name: Date: Name: Date: Name: Date: Section IV - ALLERGIES: Do you have any known drug allergies? Please select oneYesNo If so, please list all medications you are allergic to. Medication Name: Allergic Reaction Type: Medication Name: Allergic Reaction Type: Medication Name: Allergic Reaction Type: Are you allergic to Iodine Latex Tape Shellfish Eggs Sulfa Current Medications: Please list ALL medications you are taking, with dosage and prescribing doctor's name. Medication Name: Dose Strength: Medication Name: Dose Strength: Medication Name: Dose Strength: PSYCHIATRIC HISTORY Are you currently seeing a psychiatrist or psychologist? Please select oneYesNo If yes, Whom? Have you had any recent thoughts or ideations of suicide or harming others? Please select oneYesNo SOCIAL HISTORY What is your occupation: What is your occupation: Do you smoke? Please select oneYesNo If yes, what and how much? Do you drink alcohol? Please select oneYesNo If yes, what and how much? Do you take Street drugs? Please select oneYesNo If yes, what and how much? Have you ever abused narcotic or prescription medications? Please select oneYesNo If yes, what ? I agree to the follwoing terms and conditions
