JAMES PETROS, M.D., INC. PHONE: (408) FAX: (408)

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1 FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) FAX: (408) Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex: M Social Security Number: F Occupational Injury (Work Comp) Date of Injury/Accident: Claim Number: Address: (Street, City, State, Zip) Mobile Number: Alternate Number: Employer: Adjuster Name: Primary Care Physician Primary Care Name: Primary Insurance Information Adjuster Personal Injury Date of Injury/Accident: Policy Number: Claim Number: Attorney Subscriber: Attorney Name: Group Number: Address: (Street, City, State, Zip) Secondary Insurance: Fax Number:

2 1 What is/are your goal(s) for this visit? 2 Did your pain begin: Suddenly? Gradually? Other? 3 6 When did your pain (and associated symptoms) begin? 7 Draw the location of your pain on the body outlines below. Use the following keys: Ache /// Burning BBB Numbness NNN Pins & Needles XXX Stabbing +++ Other OOO How did your pain begin? Accident (Type of ): Right Left Left Right Illness: 4 Does your pain travel? 5 a) If yes, explain: Which of the following accompany your pain? (Explain) Numbness Tingling with pins & needles Weakness Muscle Spasms/Tightness Coldness Bowel Problems Bladder Problems Increased Sweating Skin Changes Circle your level of pain intensity: 1 2 Least pain Most pain Additional Comments:

3 8 What is the frenquency of your symptoms? Constant Intermittent Hourly 9 Daily Weekly What makes your pain worse? 12 Sitting Standing Walking Bending thing Sleeping Rest Away from work Sitting Standing Walking Exercise Laying Job duties, explain: 10 What treatments have helped your pain in the past? impacted by your pain? Sleep Appetite Concentration Emotions Family Social Relationships Sexual Activity Work Activity Medicine (List): 11 Physical Therapy Chiropractic Acupuncture Psychotherapy Since your pain began, has it: Decreased? Increased? Remained the same? Alcohol Physical Therapy Chiropractic Acupuncture Heat Application Cold Application Medicine (List): 13 Which of the following is/are negatively Medical Procedures or Surgery: (Describe) 7. What makes your pain better? 14 Which of the following tests have you had for evaluation of your pain? X-ray MRI CT Scan EMG (Nerve Study) Myelogram

4 14 Personal Medical History 18 Surgical History High blood pressure Diabetes Stroke Anemia Thyroid Disease Arthritis Depression Cancer, type: Heart problems, type: Lung problems, type: Other(s), list: 15 Allergies 19 Medications (include full list with dosages) 16 Social History 20 Martial Status? Single Children? Married Divorced Widowed How long have you worked at this job? Do you have a history of illegal drug abuse?,type: Do you exercise regularly? 17 Years Months Have many hours per day do/did you work? Do you drink alcohol? Current Employer: Job Position: Work Duties: Do you smoke cigarettes? Work History (work comp only) How many days per week do/did you work? Are you currently working?, Full Duty, explain: Family History Diabetes Heart Disease Cancer, type: Other(s), list:

5 Reviews of Systems (please check all that apply): General Fevers Chills Night Sweats Fatigue Weight Loss Appetite Loss Poor Sleep Head/Ears/Eyes/se/Throat: Vision Problems Decreased Hearing Ringing in Ears Ear Pain Runny se Nasal Congestion Sore Throat Sinus Problems Allergies Cardiovascular Chest Pain Swollen Legs Palpitations (Fluttering) Respiratory Skin Shortness of Breath Cough Wheezing Pneumonia Bronchitis Rash Abnormal Hair Loss Nail Problems Genitourinary Painful Urination Increased Urinary Frequency Increased Urinary Urgency Blood in Urine Abnormal Discharge Bladder Incontinence Hematologic Taking Blood Thinners Easy Bruising/Bleeding Psychiatric Depression Anxiety Anger Issues Musculoskeletal Joint Pain Muscle Pain Weakness Wasting Swelling of Joints Arthritis Neurologic Dizziness Fainting Headaches Seizures Hallucinations Paralysis

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