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Reason for your Visit
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New Patient Visit
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Follow-up
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Post-Op
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Please describe your symptoms.
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Click on the Free Draw button to illustrate your area of pain. (Only on iPad)
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Are your symptoms the same as last visit?
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Please rate your pain (0=no pain to 10=worst).
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Do you have any weakness?
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If "Yes" where?
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Do you have any numbness/tingling?
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If "Yes" where?
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What makes your pain better?
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Please select:
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What makes your pain worse?
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Please select:
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Previously tried treatment(s):
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Physical Therapy
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Where did you receive physical therapy?
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Did it help?
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Did it make it worse?
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Steroid Injections
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Did it help?
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Other therapies:
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If spinal surgery was performed, was it helpful?
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Review of Systems
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Do you presently have any problems or symptoms in the following areas?
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New Surgical History
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Past Neck Surgery:
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Neck Procedure
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Procedure Date:
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Doctor:
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Past Back Surgery
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Back Procedure
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Procedure Date
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Doctor
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Social History Changes
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Have you quit smoking recently? (if applicable)
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If "yes" when?
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Have you adjusted your alcohol or recreational drug use? (if applicable)
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Describe:
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Do you exercise?
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Describe:
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How did you hear about our practice?
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Who referred you to our practice?
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Practice Name
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New Patient Health History
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Please describe your symptoms.
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Click on the Free Draw button to illustrate your area of pain. (Only on iPad)
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How long have you had these symptoms?
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Please rate your pain (0=no pain to 10=worst).
• • •
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Do you have any weakness?
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If "Yes" where?
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|
Do you have any numbness/tingling?
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If "Yes" where?
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|
What makes your pain better?
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Please select:
• • •
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What makes your pain worse?
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Please select:
• • •
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Previously tried treatment(s):
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Physical Therapy
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Did it help?
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Steroid Injections
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Did it help?
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Other therapies:
• • •
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Is this the result of a specific injury or accident?
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Date of accident
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Type of accident
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Are you involved in litigation regarding this condition?
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Medical History
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Select all that apply
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Do you currently have any problems or symptoms in the following areas?
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Past Neck/Back Surgical History
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Choose the type of surgery
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Family Health History
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Father's Medical Health
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Comments
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Mother's Medical Health
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Comments
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Sibling(s) Medical Health
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Comments
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Grandparent's Medical Health
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Comments
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Children's Medical Health
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Comments
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Social History
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Tobacco Use
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# packs a day
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When did you start smoking?
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Year you quit smoking?
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Former smoker
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Alcohol use
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Alcohol consumption
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Caffeine
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Exercise
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Recreational Drug Use
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How often and what substance?
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How did you hear about our practice?
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Who referred you to our practice?
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Practice Name
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