New Patient History / Eval Form "*" indicates required fields EmailThis field is for validation purposes and should be left unchanged.Patient Name* Date MM slash DD slash YYYY GenderSelectMaleFemaleAddressDate of Birth MM slash DD slash YYYY Insurance NameMember IDEmail* Phone Number*Referring PhysicianName*Address*Phone*FaxPrimary Care Physician Name*Address*Phone*FaxIf Not Referred by a Physician, How Did You Hear About Our Practice?*DESCRIBE YOUR PAIN Main Reason for Visit:How & When Did the Pain Start?Have You Ever Had This Pain Before? Yes No If Yes, How Long Ago?Describe Your Pain (Check All That Apply) Throbbing Cramping Shooting Pressure Weakness Intermittent Tiring/Exhausting Numbness/Tingling Stabbing Aching Dull Spasms Constant Hot/Burning Sharp Others Pain is Aggravated by (Check All That Apply) Bending Exercise Sitting Walking Lifting Movement Standing Lying Down Changing Position (Sitting to Standing) Other Pain is Alleviated by (Check All That Apply) Bending Ice TENS unit Sitting Mild Stretching Hot Packs Rest Lying Down Other Do You Have Any of the Following Symptoms? Bowel/Bladder Incontinence Muscle Weakness Numbness/Tingling List All Medications You Have Used to Treat This Pain in the PastHave You Had Any of the Following Tests to Evaluation Your Pain? (Provide Date & Facility)X-Rays Yes No MRI Yes No CT Scan Yes No Myelogram Yes No EMG Yes No Blood Tests Yes No Bone Scan Yes No Discogram Yes No Current/Previous Treatments for this Pain Epidural Steroid Injections Physical Therapy Chiropractic Therapy Massage Therapy Acupuncture Psychiatry / Psychology / Biofeedback How ManyTypeDate of Last Injection MM slash DD slash YYYY Facility/PhysicianHow Long was PT triedHow Long was Chiro TriedHow Long was Massage TriedHow Long was Accu. TriedDaysWeeksMonthsYearsFrequencyX perRelief None Mild Moderate Excellent Relief LastedDaysWeeksMonthsYearsProviders NameOffice Phone NumberExplainCURRENT MEDICATIONSList All Medications You Are Currently Taking (Include Prescriptions, Over-the-counter, Vitamins & Supplements)Medical History (Check All That Apply) Neck Pain Back Pain Compression Fractures Osteoporosis/Osteopenia Herniated Disc Headaches Fibromyalgia Chronic Fatigue Syndrome Arthritis Gout Cancer Prostate Disease Breast Disease Bleeding Disorders Stroke Seizures Pneumonia Diabetes Hepatitis Heart Burn/Reflux Stomach Ulcers Heart Disease Angina COPD (Emphysema) Chronic Wounds Glaucoma Macular Degeneration Hearing Loss Thyroid Disease Depression Anxiety Bipolar Disorder Urinary Tract Infection Incontinence Kidney Stones Erectile Dysfunction High Blood Pressure High Cholesterol Blood Clots Pulmonary Emboli Coronary Artery Disease MI / Heart Attacks Congestive Heart Failure Atrial Fibrillation Other LocationTypeCircle Type 1 Type 2 Circle A B C Allergies (All Including Medication, Food), Indicate Reaction Yes No Known Drug Allergies (NKDA) If Yes ExplainSurgical History (Check All That Apply) None Cervical Surgery Lumbar Surgery Thoracic Surgery Kyphoplasty Vertebroplasty Spinal Surgery Orthopedic / Joint Cataracts LASIK Endoscopy/Colonoscopy Tonsillectomy/Adenoidectomy Thyroidectomy Coronary Bypass Cardiac Stent Pacemaker Heart Valve Gall Bladder Hysterectomy C-Section Bowel/Stomach Resection Hernia Prostate surgery Other Cervical Surgery ProcedureLumbar Surgery ProcedureThoracic Surgery ProcedureSurgeonSurgeonSurgeonYearYearYearFamily History Back/Neck ProblemsRelationAge @ DiagnosisCurrent AgeDepression/Mood Disorders RelationAge @ DiagnosisCurrent AgeHigh Blood Pressure RelationAge @ DiagnosisCurrent AgeDiabetes RelationAge @ DiagnosisCurrent AgeCancer (list type) RelationAge @ DiagnosisCurrent AgeOtherFatherAlive Yes No Current AgeAge at Death (If Applicable)Cause of Death (If Applicable)Health ProblemsMotherAlive Yes No Current AgeAge at Death (If Applicable)Cause of Death (If Applicable)Health ProblemsBrothersAlive Yes None UntitledCurrent Ages(s)Age at Death (If Applicable)Cause of Death (If Applicable)Health ProblemsSistersAlive Yes None UntitledCurrent Ages(s)Age at Death (If Applicable)Cause of Death (If Applicable)Health ProblemsSocial HistoryAlcohol Use None Yes Number of Drinks Per DayFrequency Daily Weekly Monthly Rarely Type of AlcoholTobacco Use None Yes Quit Smoke, or OtherAmount Per DaySinceDate QuitOther Recreational Drug Use None Yes What DrugsFrequency Daily Weekly Monthly Rarely Do You Drive? Yes No Do You Always Wear a Seatbelt? Yes No Sometimes Do You Exercise? Yes No If Yes, How Often?Work Status Employed Full-time Part-Time Unemployed Retired Disabled Current/Former OccupationAre You on Disability? Yes No Marital Status Married Single Widowed Domestic Partnership With Whom Do You Live? Alone Spouse Child(ren) Parents Friends Other Do You Have an Attorney or Legal Action Pending Related to This Pain/injury or Any Other Health Problems? Yes No If Yes, Please List Attorney’s NameReview of Systems (Check All That Apply) General Weight Loss or Gain Fatigue Fever or Chills Weakness Trouble Sleeping Other Skin Rashes Lumps Itching/Dryness Color Changes Hair/Nail Changes Other Neck / Breasts Lumps Swollen Glands Pain or Stiffness Discharge Breast-Feeding Other Vascular Calf Pain w/Walking Leg Cramping Other Hematologic Easy Bruising Easy Bleeding Other Cardiovascular Chest Pain or Discomfort Palpitations Short of Breath w/Activity Difficulty Breathing Lying Down Swelling Sudden Awakening From Sleep Short of Breath Respiratory Cough Sputum Coughing up Blood Shortness of Breath Wheezing Painful Breathing Other HEENT Headaches Head Injury Earache Decreased Hearing Vision Loss/Changes Glaucoma Cataracts Nose – Stuffy/Discharge Hayfever, Itching Nose Bleeds Sinus Pain Sore Throat Dry Mouth Non-healing Sores Dentures Thrush Other Endocrine Heat/Cold Intolerance Sweating Frequent Urination Thirst Change in Appetite Other Gastrointestinal Difficulty Swallowing Change in Appetite Heartburn Nausea Change in Bowel Habits Rectal Bleeding Constipation Diarrhea Yellow Skin / Eyes Urinary Abnormal Frequency Abnormal Urgency Burning or Pain Blood in Urine Incontinence Change in Urinary Strength Other Musculoskeletal Muscle/Joint Pain Stiffness Back Pain Redness of Joints Swelling of Joints Trauma Other Neurologic Dizziness Fainting Seizures Weakness Numbness/Tingling Tremors Other Psychiatric Nervousness Stress Depression Memory Loss Other OtherCAPTCHA
