New Patient Evaluation
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- Dwain Shaw
- 10 years ago
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1 What area hurts you the most? (Please choose one) When did this pain start? Neck Other: Back How did this pain start? How often do you experience this pain? Describe what this pain feels like. What makes this pain worse? Work related injury Motor Vehicle Accident Fall No known cause Other Constantly Frequently Intermittently Occasionally Burning Aching Electrical Sharp Throbbing Spasms Other: Bending Backward Overhead Activity Sneezing Coughing Bending Forward Looking Up Other: What makes this pain better? Medication Massage Heat Ice Traction Lying flat on back Other: If pain is worse in your neck or back, does it extend into your arms or legs? Yes, arm (s) Yes, leg (s) No If yes, how often does this pain go into your arms or legs? Constantly Frequently Intermittently Occasionally If yes, what does the pain in your arms or legs feel like? Burning Shooting Numbing Aching Electrical Other: If the main pain complaint is neck pain, do you have headaches that occur as a result? If yes, what does your headache pain feel like? Yes No Burning Shooting Throbbing Pulsing Crushing Dull & Achy Electrical Sharp Pulling Toothache like Stabbing Spasms Tingling Numbing Other: Sinuses Behind the eyes Forehead Side of head 1
2 Where do you experience your headache pain? Top of head Back of head Entire head Other: What triggers your headache pain? Stress Strong smells Too little/much sleep Weather changes Caffeine Neck movement Certain foods/alcohol Other: How frequent are your headaches? Are any of the following associated with your headaches? Constantly Daily 1-2/week 3-5/week 1-2/month Floaters/visual changes Sensitivity to sound Sensitivity to light Nausea Vomiting Other: Does your pain keep you awake at night? If yes, please explain:_ What is your pain intensity today, with 0 representing no pain and 10 representing the most severe pain imaginable? Do you experience any other areas of pain? If yes, please proceed below. If no, please proceed to page 4. In what other areas do you Neck Other: Back experience pain? When did this pain start? Yes No How did this pain start? How often do you experience this pain? Describe what this pain feels like. What makes this pain worse? Work related injury Motor Vehicle Accident Fall No known cause Other Constantly Frequently Intermittently Occasionally Burning Aching Electrical Sharp Throbbing Spasms Other: Bending Backward Overhead Activity Sneezing Coughing Bending Forward Looking Up Other: 2
3 What makes this pain better? Medication Massage Heat Ice Traction Lying flat on back Other: If your pain is in your neck or back, does it extend into your arms or legs? Yes, arm (s) Yes, leg (s) No If yes, how often do you experience your arm or leg pain? Constantly Frequently Intermittently Occasionally If yes, what does your arm or leg pain feel like? Burning Shooting Numbing Aching Electrical Other: If your pain complaint is neck pain, do you have headaches that occur as a result? Yes No If yes, what does your headache pain feel like? Where do you experience your headache pain? What triggers your headache pain? Burning Shooting Throbbing Pulsing Crushing Dull & Achy Electrical Sharp Pulling Toothache like Stabbing Spasms Tingling Numbing Other: Sinuses Behind the eyes Forehead Side of head Top of head Back of head Entire head Other: Stress Strong smells Too little/much sleep Weather changes Caffeine Neck movement Certain foods/alcohol Other: How frequent are your headaches? Are any of the following associated with your headaches? Constantly Daily 1-2/week 3-5/week 1-2/month Floaters/visual changes Sensitivity to sound Sensitivity to light Nausea Vomiting Other: Do you have any other areas of pain? If yes, please list below and describe. 3
4 Pain Treatment History Please check all of the treatments you have tried for your pain and then complete the appropriate column at the right to the best of your ability. Not Tried Excellent Relief Moderate Relief No Relief Made Worse Surgery Injections Physical Therapy Chiropractic Therapy Psychotherapy If you have had injections, please specify what kind: What year were they done? Functional/Occupational Limitations During the past month, place a checkmark next to the activities you avoided because of pain: Going to work Performing household chores Caring for self Having sexual relations Socializing with friends Participation in recreation Physically exercising Other: Have you had to stop working or change work related activities? If yes, please explain: Have you filed any legal claims related to your pain problems? If yes, please explain: Please check if the family member listed has suffered from any of these medical conditions: Family History Stroke Heart Attack Cancer Diabetes Mother Father Brother Sister 4
5 Past Medical History Please place a check by the medical conditions you have been diagnosed with. Coronary Artery Disease Heart Attack High Cholesterol Pacemaker Defibrillator High Blood Pressure Stroke Migraines Dementia Osteoarthritis Transient Ischemic Rheumatoid Asthma Sleep Apnea COPD Attack (TIA) Arthritis Degenerative Joint Emphysema Bleeding Disorder Glaucoma Fainting Disease Gastro esophageal GI bleeding Kidney Stones Hepatitis HIV/AIDS Reflux Disease (GERD) End Stage Renal Disease Diabetes Hypothyroidism Hyperthyroidism Shingles Benign Prostatic Hypertrophy (BPH) Psoriasis Staph infection Erectile dysfunction (ED) Cancer (please list type): Other: Past Surgical History Please list any surgical procedures you have had done and the year they were performed. Surgery Year Please list all the Physicians that are currently treating you: Name Specialty Location 5
6 Review of Systems Please check all that apply to your health: Chest pain Shortness of breath Extremity swelling Constipation Unintentional weight gain Bowel incontinence (loss of stool control) Urinary incontinence (loss of bladder control) Gastric upset/discomfort Rash Numbness Weakness Sensory changes Nausea Unintentional weight loss Altered mental status Confusion What is your relationship status? Social History Single Married Separated Divorced Widowed What city do you live in? Who do you live with? What is the highest level of High School diploma GED 2 year degree education you have 4 year degree Graduate degree Other: completed? Please check yes or no to the following: Do you smoke? If yes, how much: If you quit, how long ago was that: Do you use other nicotine products? Do you drink alcohol? If yes, how many alcoholic beverages do you drink in a week: Have you abused alcohol or been diagnosed with alcoholism? Have you used illegal drugs? Have you ever abused pain, sleep, anxiety, cold, psychiatric, diet or any other prescription medications? Has a parent or sibling abused alcohol or been diagnosed with alcoholism? Has a parent or sibling used illegal drugs? Has a parent or sibling ever abused pain, sleep, anxiety, cold, psychiatric, diet or any other prescription medications? Have you ever been in a detoxification program for drug abuse? Have you ever been treated at a Methadone clinic? Have you ever participated in Alcoholics Anonymous? Do you suffer from physical abuse or safety hazards in your current living situation? If yes, please explain: Were you a victim of childhood sexual abuse? 6
7 Yes No Psychological History Please check yes or no to the following: Have you ever attempted suicide? Do you have suicidal thoughts? Have you ever been hospitalized for psychiatric issues? If yes, please explain: Are you currently under the care of a psychiatrist? Who? Have you been diagnosed with or suffer from Attention Deficit Disorder (ADD)? Have you been diagnosed with or suffer from Obsessive Compulsive Disorder (OCD)? Have you been diagnosed with or suffer from Bipolar disorder? Have you been diagnosed with or suffer from Schizophrenia? Have you been diagnosed with or suffer from Anxiety? Have you been diagnosed with or suffer from Depression? Medications Please list all the medications you currently take including vitamins/herbs/supplements. Please be sure to BRING IN YOUR MEDICATION BOTTLES to your appointment. Medication Name Dose (mg, mcg, etc) Route it is taken (by mouth, injected, etc) Frequency it is taken (once a day, twice a day, etc) 7
8 Notes: For clinic use only: 8
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