Buckeyespineandrehab.com



Patient _____________________________________ DOB ___________________ Date ______________ Reason for today’s visit:How long have you had these symptoms?How did you develop these symptoms? Was there a specific cause?Since your symptoms began, you are: (Please circle one): Better / No Change/ Worse / ImprovingAre your symptoms (please circle one): Intermittent ConstantWhere do you hurt:Describe your pain or symptoms:Sharp / Aching / Throbbing / Muscle Spasm / Muscle Cramping / Cramping Burning / Shooting / Stabbing / Electric / Pins and Needles / Tingling / Piercing / CuttingOther:Does your pain or symptoms radiate anywhere? Yes No If so, where?How did you develop these symptoms? Was there a specific cause?What makes you feel better?What makes you feel worse?Does your pain or discomfort keep you awake at night or wake you up? Yes NoRate todays level of pain (0 no pain, 10 worst pain ever)(please circle one): 0 1 2 3 4 5 6 7 8 9 10Rate your worst level of pain since onset symptoms (0 no pain, 10 worst pain ever)(please circle one): 0 1 2 3 4 5 6 7 8 9 10Please rate your lowest level of pain since onset of symptoms (0 no pain, 10 worst pain ever)(please circle one): 0 1 2 3 4 5 6 7 8 9 10Do you have weakness?If yes, where:Do you have numbness? If yes, where:Please circle diagnostic tests you have had for this condition When did you have the test Name of FacilityX-Rays Yes / No ______________________ ____________ MRI Yes / No ______________________ ____________CT Scan Yes / No ______________________ ____________EMG/NCS/ Nerve Test Yes / No ______________________ ____________Other:Treatments. Circle any of the following treatments you have tried:Physical Therapy: If you had Physical therapy, What is the name of the Facility and when did you have it last? Manipulation: Massage: Acupuncture: Joint Injections:TENS Unit:Spine Injections: Epidural Steroid Injections: Facet Joint Injections: Sacroiliac Joint Injections: Surgery: Please list the Medications you are currently taking for THIS condition and how you take them: Does It Help?A)________________________________________________________ Yes NoB)________________________________________________________ Yes NoC)________________________________________________________ Yes No D)________________________________________________________ Yes NoPlease list the MEDICATIONS you have TRIED IN THE PAST FOR THIS CONDITION: Please list ANY OTHER MEDICATIONS you are CURRENTLY taking: Please list all physicians, chiropractors, surgeons and providers you have seen for this condition:Do you perform a Home Exercise Program ? (please circle) Yes / NoWork Status (Please circle one) Working / Working with restrictions / Permanently Disabled / Temporarily Disabled / Retired / In School / Unemployed If you are currently working, please give job title:Which is your dominant hand? Right LeftREVIEW OF SYSTEMS: Please circle those you have:Chills / Fatigue / Fever / Night Sweats / Weight Gain / Weight Loss / Hives / Blurred Vision Sore Throat / Excessive Thirst / Frequent Urination/ Shortness of Breath/ Cough / Chest Pain / Bowel Incontinence/ Blood in Stool / Constipation / Heartburn / Swollen Glands / Difficulty Urinating / Bladder Incontinence / Muscle Aches / Painful Joints / Pain or cramping legs after exertion / Ulceration of feet / itching / Rash / Loss of Strength Tingling / Numbness / Anger / Feeling down, depressed or hopeless / Little interest or pleasure in doing things / Anxiety / Depressed mood / Difficulty sleeping / Substance abuse / Pain awakening you from sleepAllergies: ________________________________________________________ Allergic to Shellfish/Iodine/Seafood ? Yes ? No? No Known Allergies Past Medical HistoryPlease check any of the following medical conditions you have or have had:?Diabetes? Thyroid Disease ?Coronary Artery Disease ? Heart Attack ? Heart Failure ? High Blood Pressure ?Atrial Fibrillation ?Blood Clots ?Stomach Ulcers ? Gastritis ?Liver Disease ?Colitis ?GI Bleeding ? Hepatitis ? Headache? Seizures ? Neuropathy ?Parkinson’s Disease ? Restless Legs ? Multiple Sclerosis ? Stroke ? Osteoarthritis? Gout ? Fibromyalgia ? Lupus ? Osteoporosis?Rheumatoid Arthritis ?HIV/AIDS ? Anemia ? Easy Bleeding/Bruising ?Asthma? Bronchitis/COPD ? Tuberculosis?Anxiety?Depression ? Bipolar Disorder ? PTSD ? Schizophrenia ?Alcoholism? Nervous Breakdown ? Drug Use Disorder?Kidney Failure? Bladder Infections ? Incontinence ?Current or previous treatment for Alcohol/Drug Use DisorderYes No? Cancer, please list type:? other medical conditions, please list:Surgical HistoryPlease check the surgeries you have had:? Heart Bypass? Cardiac Defibrillator ? Pacemaker ? Heart Valve ? Cardiac stents? Appendectomy? Gall Bladder ? Gastric By-Pass ? Hysterectomy ? ovary? Carpal Tunnel? Knee Surgery? Hip surgery ? Shoulder Surgery? Neck Surgery? Back Surgery ? kidney? Greenfield filter? Tonsillectomy? Bladder Stimulator ? Spinal Cord Stimulator? Other surgeries, please list:Family HistoryPlease check any illnesses that other family/blood relatives have had:? Diabetes? Heart Disease? Aneurysm ? Stroke? Arthritis ? Alcoholism? Drug abuse? Cancer, please list type:Social HistoryDo you use:? none? cigarettes ? cigars ? snuff ? chew ? pipeHow often and how much: Do you drink:? none? beer ? liquor ? wineHow often and how much: Do you use:? none? cocaine ? speed ?PCP? marijuana/pot? other illicit drugsHave you had any accusations or convictions for illegal drugs or alcohol?? Yes? NoWhat is the last grade of education or school completed? _________________________Please list any hobbies:Patient Signature ___________________________________________________________ Date: _________________Please make sure this form is completed in full ................
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