History Questionnaire

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1 History Questionnaire Today s Date Physician Patient Information Patient s Name Is this your legal name? Street Address Mr. Miss. Marital Status (circle one) Mrs. Ms. Single Mar Div Sep Wid If not, what is your legal name? Former name Birthdate Age Sex Male Female Social Security Number Home Phone ( ) P.O. Box City State Zip Occupation Employer Phone Your Doctor Your Attorney (if any) If questions arise from today s interview, is it okay to call you? Current Problem When did your problem begin? How did it begin? Accident at work Gradually, for no apparent reason Other Accident Gradually, due to work activity Motor Vehicle Accident (For Office Use Only) Please describe, in detail, what happened What symptoms did you have initially? Type of treatment you have had, in order (list below) Response to treatment (for example: cured the problem, helped for a day or two, made it worse) Please describe your present symptoms

2 Current Symptoms Please rate any pain on a scale of 0 (no pain) to 10 (worst pain imaginable) Location of pain(s) Your pain level when problem began Your current pain level Average pain over the last month What makes pain worse? What makes pain better? Is there one time of day your symptoms are worse? (explain) Overall, are you getting better staying the same getting worse Before your current problem began, had you ever had similar symptoms? (explain) Activity Tolerance What percentage of your average day is spent sitting or lying down? Are you limited in Sitting Driving Standing Kneeling Walking Lifting Carrying Bending Reaching Pushing Pulling Climbing Squatting Are you limited in any other work, home or recreational activities? (explain) Do you exercise? (what do you do?) Do you have hobbies? (what are they?) Are you allergic to any medication or x-ray dyes? Medical History / Surgery (please list medications and your reactions) Medications List the dates and any types of surgeries you have had

3 Review of Systems I have been treated, or am currently being treated for problems associated with Neck Problems Other Bone & Joint Neurological Problems Kidney Disease Hip Problems Foot Problems Gout Colon/Rectal Disease Anxiety Physical, sexual, emotional abuse Wrist/Hand Shoulder Heart Disease Cancer Depression Back Problems Ankle Problems Skin Problems Psychological Problems Difficulty Sleeping Elbow Problems Arthritis Lung Disease Diabetes Feelings of Worthlessness Knee Problems Circulation Problems Liver Disease Other (explain below) Irritability Rate your general health Excellent Good Fair Poor Work History Were you employed when your problem began? If yes, job title Employer How long had you worked prior to the onset of your problem In your job, how many hours of the day do you spend Sitting Driving Standing Assuming that OCCASIONALLY means up to 1/3 of the time, FREQUENTLY means 1/3 2/3 of the time, and CONSTANTLY means 2/3 to all of the time, did your job require Bending Occasionally Frequently Constantly Climbing Occasionally Frequently Constantly Lifting Occasionally Frequently Constantly Twisting Occasionally Frequently Constantly Reaching above the shoulder Occasionally Frequently Constantly Maximum weight you had to lift or carry Did you miss work as a result of your problem? If yes, how many Days, Weeks, Months, Years Are you working now? List reason(s) for not working If no, been off work since Did you enjoy the work? Did you get along with your supervisor? Is your job still available? Did your employer treat you fairly? Did you get along with your Co-workers? Amount of control you had at work Amount of stress you had at work Are you receiving disability compensation payments? If yes, Worker s Comp. Social Security Private Disability Insurance Other Amount of payments per month: $ Monthly wages/salary while working: $ Do you plan to return to work, doing, When: Do you have a driver s license? If working, what is your current job title Walking Vocational retraining is t planned Is Planned Underway Completed In what field? Prior Jobs Job Title Employer Approx Dates (MM/YY MM/YY) Other

4 Do any physical or mental problems run in your family? If yes, explain Is anyone in your family disabled? Explain the disability Family History If yes, who? Social History Marital Status (expanded) Single Never Married Separated Divorced Widowed Number of Children (if any) Number of children dependent on you Living Situation You Live alone, Live with spouse only, Live with spouse and children, Live with significant other, Live with friend Substance Usage Do you smoke? pack(s) a day for years. How many alcoholic beverages do you consume per week? Did you smoke, drink, or use illegal drugs in the past? If yes, what, how much, and for how long? Do you use alcohol or unprescribed medication for pain? Education Completed th grade Graduated High School Obtained GED Had year(s) of vocational training in Had year(s) of college but did not graduate Graduated from college with an associate bachelors masters doctoral degree Military History Were you in the military? Air Force Army Marines Navy Coast Guard Years of Service Type of Discharge Any service related disability? % for

5 Motor Vehicle Accident History (If Applicable) Name You were Driver Front Passenger Rear Passenger, left Date of accident Rear Passenger, right Rear Passenger, Center Your Vehicle: year / make / model Other Vehicle: year / make / model Seat type Bucket Bench Seat had Headrest Highback Neither Top of headrest (or seat back) was - Above Below At - the center of your ear Distance between the back of your head and the headrest was inches (or) Don t know Your vehicle had airbag for Driver Front passenger Side impact Don t know Did the airbag(s) deploy You were wearing Shoulder and Lap belt Shoulder belt only Lap belt only belt Your vehicle Hit another Was hit On Street Freeway Other Road Surface was Dry Wet Icy Snow covered Speed of your vehicle at time of impact Other vehicle s speed Damage to your vehicle was to Front Rear Left Side Right Side Approximate dollar amount of damage to your vehicle: $ Was there damage to the interior of your vehicle, what was the damage? Did you see the collision coming, what did you do? Describe your body position at impact including head-neck, hands, and feet Describe what happened to your body when the collision occurred Did you lose consciousness?, how long? You left the accident in Same vehicle Ambulance Other vehicle Did you have more symptoms later?, if so, what were they and when did they start?

6 Patient s Name Patient Pain Drawing For Office Use Only Mark the areas of your body where you feel the described sensations. Use the appropriate symbols (as shown). Include all affected areas. Just to complete the picture please draw in your face. Ache Numbness Pins & Needles Burning Stabbing xxxxx ////// Back Front Pain in the arm(s) compared to neck Worse than Same as Less than Pain in the leg(s) compared to neck Worse than Same as Less than Signature Date

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