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Where did you find us?
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Which specialists do you see?
• • •
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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What is your main complaint?
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When did it start(if unsure,give approx onset)
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Did anything occur to cause the pain?
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Describe the pain(i.e. dull, sharp, ache, other)
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Any radiation of the pain?
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If so, describe_____
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What makes the pain better?
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What makes the pain worse?
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Any associated weakness in an arm or leg or both
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Any numbness/tingling or both?
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Where? (ie. in an arm or leg)?
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Rate the pain scale(10 excruciating,1 none)
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Rate the range of pain(lowest to highest level)
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Prior treatment for this condition?
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Had prior treatment(s), which one(s) helped
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Activities affected by this painful condition?
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Do you have any of the following other complaint
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Medical History
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Heart disease
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CVA(stroke)
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If without Stomach ulcer(with/without bleeding)
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If Diverticulosis, with/without bleeding?
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If other instestinal disorder, please specify
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Arthritis
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Cancer
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If other, please specify
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metastases=spread
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Other medical problem (ie.ever been hospitalized
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Surgical history
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If Spinal surgery, please specify
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If other, please specify
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Medication list (include pain meds)
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Allergies to medications:
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Other allergies (ie. foods, environmental, etc)
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Family history (close relatives):
• • •
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If cancer, please mention type of cancer
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Social history
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If smoking, how much____ppd)
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If alcohol (how much__drinks/wk)
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If drug abuse, what and last use?
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Occupation
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Work Status
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If disability, permanent or temporary
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Family
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25) Have you ever had the pneumonia vaccine?
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26) Did you get the flu vaccine during the past
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