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MRN#Date:Patient Medical QuestionnairePatient Name Date of BirthHome AddressAge Height Weight Sex M / F (circle)Referring PhysicianCHIEF COMPLAINT (Why are you here today?):Date symptoms began Is this related to an accident?Yes / No (circle)If yes, is workman’s comp involved? If yes, is there litigation involved?Have you been treated with any of the following?Pain Medicationx WeeksAnti-Inflammatoriesx WeeksPhysical Therapyx WeeksChiropractorx WeeksEpidural Steroid Injection: Y / N (Circle)How many?These provided relief for:No relief1-2 weeks1-2 months>2 monthsPAST MEDICAL HISTORYCheck box if you have been diagnosed with any of the following:?Heart Disease?Rheumatoid Arthritis?Heart Attack?Osteoarthritis?High Blood Pressure?Kidney Failure?High Cholesterol?Stomach Ulcers?Pacemaker?HIV / AIDS?Diabetes?Depression?COPD or Chronic Bronchitis?Anxiety?Asthma?Alcoholism?Stroke or TIA?Drug Addiction?Peripheral Vascular Disease?Migraines?Aneurysm?Fibromyalgia?Hepatitis, if so circle which one A B C?Bipolar?Cancer, if so which kind(s) ???????List any other medical conditions?????PAST SURGICAL HISTORY:Please list all surgeries along with the date and surgeon who performed it.MEDICATIONS & VITAMINS (Include over the counter medications)NameDosageUse the back of this sheet if you need more spaceAre you currently being treated by a pain management physician? Yes / No (circle)Are you under a narcotic agreement? Yes / No (circle)ALLERGIES (Please list allergies to medicines)FAMILY HISTORY (Please check if your relatives have had any of the following)?MotherFatherSiblingGrandparentChildCommentsHeart Disease??????High Blood Pressure??????High Cholesterol??????Diabetes??????Stroke??????Kidney Failure??????Cancer??????Aneurysm??????Psychiatric Illness??????Other (please explain in comments)??????SOCIAL HISTORYDo you smoke? Yes / No (circle)If yes, how much per day and how long? Do you drink alcohol? Yes / No (circle)If yes, how much?Do you do any illicit drugs? Yes / No (circle) If yes, which ones? Occupation Do you still work?Are you on disability? Yes / No (circle)If yes, why?Review of Symptoms: (Please check all that apply)CONSTITUTIONALFeverChillsNight sweatsWeight lossWeight gainSleep disturbanceLack of energyEYESDouble visionBlurred visionVision lossEye painSensitivity to lightEAR/NOSE/THROATHearing lossDizzinessRinging in earsNosebleedsSore throatHoarsenessTrouble swallowingCARDIOVASCULARChest painPalpitationsFainting spellsAnkle swellingRESPIRATORYCoughWheezing/AsthmaCoughing up bloodShortness of breathSleep ApneaEmphysemaGASTROINTESTINALConstipationNauseaVomitingDiarrheaRefluxUlcerAbdominal painDark tarry stoolRectal bleedingJaundiceGENITOURINARYUrinary frequencyLoss of bladder controlPainful urinationImpotenceSexual dysfunctionPelvic painKidney stonesVaginal bleedingBlood in urine MUSCULOSKELETALJoint swellingArthritisMuscle painTrouble walkingJoint painLow back painNeck painSKINRashItchingDrynessSuspicious lesionNEUROLOGICHeadachesNumbnessParalysisFalling downSeizuresWeaknessTremorMemory loss ConcussionALLERGIC/IMMUNOLOGICAutoimmune disorderSeasonal allergiesPSYCHIATRICDepressionAnxietySuicidal thoughtsParanoiaHallucinationsENOCRINECold intoleranceHeat intoleranceExcessive thirstExcessive urinationHEMATOLOGIC/LYMPHATICAbnormal bruising or bleedingHypercoaguable stateEnlarged lymph nodesOTHER: Please describeAre you claustrophobic? Yes / No (circle)Have you ever had a problem with anesthesia? Yes / No (circle)Physician’s signature Date ................
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