PATIENT HISTORY QUESTIONNAIRE

Your appointment is on:             

Date________________

Patient Name:                                                          Date of Birth __________________ Age _____

Phone (               )________________________Cell Phone (                )__________________________

Address_____________________________ City _______________________ State ____ ZIP _____

Primary physician _________________________ Clinic & City ______________________________

Referring physician _________________________ Clinic & City _____________________________

Education (state last grade completed) __________ Occupation _____________________________

Employer _______________________________ Phone _________________ For how long? _____

Is this Worker’s Compensation? Yes [   ] No [   ]                      Date of injury ___________________

Is your current work physically demanding? Yes [   ] No [   ]

Are you currently working outside the home? Yes [   ] No [   ]          Social Sec. Number _____________

Is there a lawsuit pending your spine problem? Yes [   ] No [   ]

Ø      Spouse or Significant other(relationship)_____________________________________

Ø      Emergency contact (other than above & including phone number)________________________________

HISTORY OF PRESENT ILLNESS

CHIEF COMPLAINT           (What symptoms bring you to see the doctor?)

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Please tell us the reasons you seek treatment.___________________________________________

How long have you had this problem? (date of injury)______________________________________

How did your problem first begin?  Suddenly [   ] Gradually [   ]   Please explain:______________

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prior to the date above, have you ever had spine problems or symptoms? Please explain:_________

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What treatment have you received for this problem? (Please list in order of each occurrence including bed rest, physical therapy, braces, injections, surgery etc.)

DATE                TREATMENT/OPERATION                     BY WHOM?                  WHERE?          WERE YOU BETTER?

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                                                                                                                                    WHEN and WHERE

Have you had a myelogram?                                               Yes [   ] No [   ] _________________________

If yes, have you had a pantopaque myelogram?   Yes [   ] No [   ] _________________________

Have you had a MRI of the spine?                          Yes [   ] No [   ] _________________________

Have you had a CT scan of the spine?                               Yes [   ] No [   ] _________________________

Have you had an EMG?                                                       Yes [   ] No [   ] _________________________

Have you had discography?                                                Yes [   ] No [   ] _________________________

For each of the activities listed, please (X) the appropriate responses:

What percent of the time are you in pain? 1-25%_____ 26-50%_____ 51-75% _____ 76-100% _____

How many hours of the day are you at rest due to your pain or discomfort? _____________________

How severe is your pain (without meds)? (Circle one)   Mild   Uncomfortable   Distressing   Horrible

What medications do you now take for pain? (Include aspirin or Tylenol)

Medicine                                  Dosage/Frequency                   Reason for Medication             How long?

_______________              ______________                 _________________          _____________

_______________              ______________                 _________________          _____________

_______________              ______________                 _________________          _____________

What other medications do you routinely take for any health reason?

Medicine                                  Dosage/Frequency                   Reason for Medication             How long?

_______________              ______________                 _________________          _____________

_______________              ______________                 _________________          _____________

Do you have any known DRUG ALLERGIES?   Yes [   ] No [   ]

Please list ALLERGIES                                           DESCRIBE REACTION

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MEDICAL HISTORY: Have you had any of the following? Indicate diagnosis if established.