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Date: __________________________________
Insurance: ______________________________
Yes
No
Yes
No
Getting Better
Getting Worse
Unchanged
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
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.__________________________________________________________________________________________
Yes
No
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?
Yes
No
Did it Help?
No
Do you use a:
Yes
walker_____
Yes
No
When?_______________
Yes
No
When?_______________
brace_____
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_________________________
Yes
No
If so, what?____________________________
GI Ulcers____________________
Heart Disease____________________
Seizures___________________
Hypertension________________
Asthma_________________________
Cancer____________________
Renal Disease_______________
TB_____________________________
Hepatitis__________________
Tendency to Bleed___________
Other__________________________
SOCIAL HISTORY
Do you use tobacco products?
Yes
Yes
No
No
No
REVIEW OF SYSTEMS (Please check any of the following symptoms you have)
Do you currently have :
Fever
Weight Loss
Weight Gain
Eyes
Comments:
__________________________________
__________________________________
__________________________________
__________________________________
YES
NO
__________________________________
____ Palpitations
__________________________________
Respiratory
____ Lung Disease ____ TB ____ Bloody Sputum
__________________________________
Gastrointestinal
____ Nausea ____ Vomiting ____ Diarrhea ____ Constipation
__________________________________
__________________________________
Genitourinary
____ Urine Retention ____ Frequency ____Discoloration ____ Pain
__________________________________
Musculoskeletal
____ Muscle pain ____ Joint pain ____ Swelling
__________________________________
__________________________________
Integumentary (Skin)
____ Rash ____ Itching ____Skin lesions or skin cancer
__________________________________
Neurological
____ Headache ____Dizziness ____ Disorientation
__________________________________
__________________________________
Psychiatric
____ Depression ____ Anxiety
__________________________________
Endocrine
____ Thyroid Disease ____ Diabetes ____ Hormonal Abnormalities
__________________________________
Hematologic/Lymphatic
____ Bleeding Tendencies ____ Anemia ____ Polycythermia
__________________________________
____ Anticoagulants
__________________________________
Allergic/Immunologic
____ Immune Disorder ____ Hay Fever ____Asthma ____Eczema
__________________________________
__________________________________
PHYSICAL EXAMINATION
Height _______
Pedal Pulses
Yes
Weight _______
No
BP Sitting _______
Lungs _______
Resp _______