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SOUTHWEST NEUROSCIENCE AND SPINE CENTER MEDICAL QUESTIONNAIRE

Date: __________________________________

Primary Care Doctor: ____________________________

Patient Name: ___________________________

Referring Physician: _____________________________

Insurance: ______________________________

Age: _________ Date of Birth______________________

CHIEF COMPLAINT: ____________________________________________________________________________


_____________________________________________________________________________________________
Did this occur at work or in an auto accident:

Yes

No

What was the date of injury or onset of symptoms? __________________________________________________


Are you presently working?

Yes

No

Since your problem started is it

Date last worked ___________________

Getting Better

Getting Worse

Unchanged

HISTORY OF PRESENT ILLNESS


What are your current symptoms? ________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Physicians Notes: __________________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________

On a scale of 1-10 (10 is the worst) how SEVERE is your pain WITHOUT activity:
1
2
3
4
5
6
7
8
9
10
On a scale of 1-10 (10 is the worst) how SEVERE is your pain WITH activity:
1
2
3
4
5
6
7
8
9
10
What is the Quality of the pain?
The pain is:

Constant

Sharp

Dull

Throbbing

Aching

Burning

Intermittent (Comes & Goes)

Does the Pain wake you from your sleep?


Do you have:

Stabbing

Swelling
Weakness

Yes

No

Bruising
Numbness
Loss of Bowel/Bladder Control

Tingling
Sexual Dysfunction

What makes your symptoms WORSE? (Ex: standing, climbing stairs, coughing, lying in bed) __________________
___________________________________________________________________________________________
What makes your symptoms BETTER?

Rest

Elevation

Ice

Heat

Other____________

List 3 daily activities that you can no longer do or have difficulty doing because of the pain(putting on socks,
walking at the store, cleaning, etc PLEASE BE SPECIFIC)
1.________________________________________________________________________________________
2.__________________________________________________________________________________________
3.__________________________________________________________________________________________

Have you had previous surgery on this body part?

Yes

No

What was done:________________________________


Have you had any steroid injections for this?
How many: _____ Physician: ______________

Yes

When: ____________________________
Surgeon:__________________________

No

When:____________________________

Did they help? ______ How long did you have relief?________

Have you tried over the counter medications such as Motrin, Ibuprofen, Aleve, Tylenol?
Did they help? _______

Yes

No

Did it Help?

Where did you go for Physical Therapy?_________________________


Have you had any chiropractic treatment?

Yes

No

Did it Help?

How long did you seek chiropractic treatment? _______________


cane ____

No

How long do you get relief after above medications?______________

Have you done any Physical or Occupational Therapy?

Do you use a:

Yes

walker_____

Yes

No

When?_______________
Yes

No

When?_______________

brace_____

Have you had any of the following for this injury:

X-Ray

MRI

CT Scan

EMG

Myelogram

MEDICATIONS

ALLERGIES

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

Do you take any blood thinners such as Aspirin, Plavix, Coumadin, Etc.? __________________
PAST MEDICAL HISTORY (Please circle)
Do YOU have a history of:

diabetes

bleeding tendencies

liver disease

heart disease

hypertension

kidney disease

Cancer

GI Ulcers

Seizures

Asthma

Other_________________________

Who are your treating doctors? ____________________


Are you under treatment for chronic illness?

Yes

No

If so, what?____________________________

Please list ALL previous surgery and dates: ________________________________________________________


___________________________________________________________________________________________
FAMILY HISTORY
Diabetes___________________

GI Ulcers____________________

Heart Disease____________________

Seizures___________________

Hypertension________________

Asthma_________________________

Cancer____________________

Renal Disease_______________

TB_____________________________

Hepatitis__________________

Tendency to Bleed___________

Other__________________________

SOCIAL HISTORY
Do you use tobacco products?

Yes

Do you drink caffeinated beverages?


Do you use alcohol?

Yes

Do you use recreational drugs?

No

No What kind (cigarettes, dip, cigars)? __________ How many?_______


Yes

No

If yes, how much?_______________

If yes, how much? ___________


Yes

No

REVIEW OF SYSTEMS (Please check any of the following symptoms you have)
Do you currently have :

Fever

Weight Loss

Weight Gain

Eyes

Comments:

____ Cataract _____ Visual Loss _____Diplopia

__________________________________

____ Deviation ____Redness ____ Pain ____ Dryness

__________________________________

Ear, Nose, Throat and Mouth


____ Ringing Ears ____Deafness ____Hoarseness

__________________________________

____ Snoring ____Discharge ____Sore Throat

__________________________________

____Swelling neck glands


Cardiovascular
**Do you suffer from sleep Apnea?

YES

NO

____ Chest Pain ____ Pacemaker ____ Feet Swelling

__________________________________

____ Palpitations

__________________________________

Respiratory
____ Lung Disease ____ TB ____ Bloody Sputum

__________________________________

Gastrointestinal
____ Nausea ____ Vomiting ____ Diarrhea ____ Constipation

__________________________________

____ Heartburn ____ Rectal bleeding ____ Ulcer

__________________________________

Genitourinary
____ Urine Retention ____ Frequency ____Discoloration ____ Pain

__________________________________

Musculoskeletal
____ Muscle pain ____ Joint pain ____ Swelling

__________________________________

____ Fracture or dislocation ____ Neck or back pain

__________________________________

Integumentary (Skin)
____ Rash ____ Itching ____Skin lesions or skin cancer

__________________________________

Neurological
____ Headache ____Dizziness ____ Disorientation

__________________________________

____ Memory Loss

__________________________________

Psychiatric
____ Depression ____ Anxiety

__________________________________

Endocrine
____ Thyroid Disease ____ Diabetes ____ Hormonal Abnormalities

__________________________________

Hematologic/Lymphatic
____ Bleeding Tendencies ____ Anemia ____ Polycythermia

__________________________________

____ Anticoagulants

__________________________________

Allergic/Immunologic
____ Immune Disorder ____ Hay Fever ____Asthma ____Eczema

__________________________________

____ Food Allergy ____ Dust ____ Animals

__________________________________

PHYSICAL EXAMINATION
Height _______
Pedal Pulses

Yes

Weight _______
No

BP Sitting _______

Carotid Bruits _______

Heart Rate _______

Lungs _______

Resp _______

Heart _______ Bowels Present ___