Patient Medical Summary

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1 Patient Medical Summary Date of Visit: Referring Physician: Reason for today s visit (chief complaint): What is/are the chief area(s) of pain? Please check all those that apply. Head Neck Upper back Lower Back Other Arm(s) Buttocks Leg(s) Shoulders Date of Injury: Was it Work Related? Was it Auto Related? Please Describe your Injury Are you experiencing any muscle weakness? Yes No Where? Are you experiencing any numbness or pain? Yes No Where? Have you experienced any of the below problems? Please check all that apply. Numbness or tingling in arm(s) Difficulty walking Poor coordination Numbness or tingling in legs(s) Tremor Weakness in arm(s) Weakness in leg(s) Is there anything that alleviates the problem? Please describe Is there anything that aggravates the problem? Please describe: Have you been to Physical Therapy in the last year? No Yes When? Did it help? Yes No Have you been to a Pain Specialist in the last year? No Yes When? Did it help? Yes No PAST MEDICAL HISTORY: Do you have a history of? Yes No Yes No Arthritis Chronic Blood Thinners Spine Injury High Blood Pressure Head Injury Hepatitis/liver disease Hiatal Hernia Kidney Disease Infectious Disease Heart Disease Stroke Ulcer Diabetes Lung/Breathing Problems Cancer Seizures/Epilepsy Fibromyalgia 1

2 FAMILY HISTORY Alive Age at Death Cause of Death Mother Father Brother(s) Sister(s) SURGICAL HISTORY Please list below, in order (most recent first), your surgical history Date Operation By Whom (doctor) Where Complications Review of Systems (please check if applicable) Increase Decrease Have you had any changes in: Activity level/stamina Appetite Weight Have you experienced any: Fever Chills Abnormal Sweating HEENT Do you have any complaints of: Visual Difficulties Dry mouth Nose Bleeds Mouth pain Difficulty hearing Ringing in ears Respiratory Do you have any complaints of: Cough Asthma Shortness of breath Wheezing Cardiac Do you have any complaints of: Chest discomfort/pain Cold hands/feet Shortness of breath Palpitations with activity Heart murmur Swelling High blood pressure GI Do you have any complaints of: Abdominal pain Constipation 2

3 Diarrhea Indigestion Heart burn Nausea/vomiting GU Do you have any complaints of: Sexual dysfunction Urinary problems Back pain Blood in urine Musculoskeletal Do you have any complaint of: Joint pain Muscle pain Joint stiffness Muscle cramps Muscle weakness Neurologic Do you have any complaints or changes in: Increase Decrease Increase Decrease Concentration Confusion Disorientation Dizziness Fainting Headaches Lightheadedness Physchiatric Do you have any complaints of: Depression Sleep Disturbances Have you ever been treated by a psychiatrist/psychologist: Yes No Endocrine Do you have a history of: Do you have any complaints of: Thyroid problems Heat intolerance Cold Intolerance Excessive thirst Hunger Excessive urination Hematologic / Lymphatic Do you have any complaints/history of: Bleeding History of anemia Bruising SOCIAL HISTORY Marital Status: Single Married Divorced Separated Other: Do you have a Living Will (advance directive) Yes No Occupation: Are you working? Last date worked: Please note your physical work requirements: Heavy Moderate Light Sedentary Smoking Status: Never Smoked 3

4 Stopped (date) Smoker currently # packs/day # cigars or pipes/day Alcohol use: Average number of alcohol drinks per day Average number of beers per day Exercise: How often do you exercise? Daily # times per week Type of exercise: Using the picture and symbols below, please mark the areas on your body where you are having problems. Please include all affected area. Aching Numbness Pins & Needles Burning Stabbing Other = = = X X X //// FRONT BACK I attest that the information noted above currently represents my symptoms and medical history. Signature Date 4

5 Physician Signature Date MEDICATIONS NAME DOSE / STRENGTH FREQUENCY (HOW OFTEN) 5

6 6

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