To help us better evaluate your condition, please complete the following form. If you have any questions we will be glad to help you. Thank you.

    Name:

    Date of Birth:

    Occupation:

    Work Status:

    Gender:

    Age:

    Marital Status:

    Height:

    Weight:

    Are you right or left handed? (select appropriate option)

    RIGHTLEFT

    Do you have any drug allergies?

    NOYES

    If “yes” list:

    Date of Injury:

    Chief complaint and brief history of present illness/injury:

    What are your hobbies/activities that you enjoy?



    Past Medical History: (Please check all that apply and provide onset, duration of symptoms and the provider who is caring for the stated issue) :

    General:

    Weight loss or gainFatigueFever or chillsWeaknessTrouble sleeping

    Skin:

    RashesLumpsItchingDrynessColor changesHair and nail changesAbnormal skin lesions

    Head:

    HeadacheHistory of traumatic brain injuryHistory of concussion

    Ears:

    Decreased hearingRinging in earsEaracheDrainage

    Eyes:

    Use of glasses or contactsVision loss/changesPainRednessBlurry or double visionFlashing lightsFloating specksGlaucomaCataractsYour last eye exam

    Nose:

    StuffinessDischargeItchingHay feverNosebleedsSinus pain

    Throat:

    BleedingDenturesSore tongueDry mouthSore throatHoarsenessThrushNon-healing sores

    Neck:

    Swollen glandsLumpsPainStiffness

    Breasts:

    LumpsPainDischargeSelf-examsBreast-feeding currently

    Respiratory:

    CoughSputumCoughing up bloodShortness of breathWheezingPainful breathingSleep apnea

    Cardiovascular:

    Chest pain or discomfortTightnessPalpitationsDifficulty breathing lying downSwellingHistory of heart attack, date ____Pacemaker

    Gastrointestinal:

    Swallowing difficultiesHeart burnChange in appetiteNauseaRectal bleedingConstipationDiarrhea

    Urinary:

    FrequencyUrgencyBurning or painBlood in urineIncontinence

    Vascular:

    Leg crampingCalf pain with walking

    Musculoskeletal:

    Muscle or joint painStiffnessBack painRedness of jointsSwelling of joints

    Neurologic:

    DizzinessFaintingSeizuresWeaknessNumbnessTinglingTremorsHistory of stroke, date: ____

    Hematologic:

    Ease of bruisingEase of bleedingKnown coagulation disorderTaking an anticoagulant such asWarfarin, Coumadin, Xarelto

    Endocrine:

    Heat or cold intoleranceSweatingFrequent urinationThirstChange in appetite

    Psychiatric:

    NervousnessStressDepressionMemory loss



    Family and Social History

    Indicate acute and chronic family illnesses:

    Health Problems:

    MOTHER:

    AliveDeceased

    FATHER:

    AliveDeceased

    SIBLINGS:

    AliveDeceased

    LIVING SITUATION:

    AloneWith others

    FUNCTIONAL STATUS:

    IndependentNeed assistance

    What is your approximate daily consumption of the following

    Coffee/tea:

    Alcohol:

    Tabacco:

    Other intoxicating drugs:



    Please List All Medicines and Dietary Supplements

    NAME OF MEDICATION DOSAGE/FREQUENCY YEARS TAKEN PRESCRIBED BY



    Previous Surgeries, Illnesses, Injuries

    TYPE OF SURGERY DOCTOR HOSPITAL APROXIMATE DATE
    TYPE OF INJURY DOCTOR HOSPITAL APROXIMATE DATE

    Is there anything else regarding your health that we should know when treating you?

    The above is accurate to the best of my knowledge.

    Sign

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