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Referring provider
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Primary Care Physician:
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Describe in your own words the primary condition you would like help with:
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When did this condition originally begin?
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What do you think caused your condition or current flare up?
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How did your current episode begin?
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Since your condition began, how has it changed?
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What are your goals for treatment?
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What is your expectation in coming to see us?
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What type of care or relief are you interested in?
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Please list any other conditions you would like to address:
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Pain History
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Does your pain radiate? If so where?
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Mark painful / distress areas with an "X" for pain, ("Z" for numbness)
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Pain Description
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Describe the character of your pain (e.g., stabbing, dull, throbbing etc.).
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What time of day is your pain at its worst?
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How often does the pain occur?
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Rate your pain on a scale
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Right now, is your pain
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What factors worsen or affect your pain?
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Other factors worsen or affect your pain
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What factors relieve your pain?
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Do you have any of the following conditions associated with your pain? (indicate all that apply):
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Are there any associated symptoms?
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Which movements trigger your pain?
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Diagnostic Tests and Imaging
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Mark all of the following tests that you have had related to your current pain complaints:
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Other Diagnostic Testing:
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Treatment History-Please mark all of the following treatments you have had.
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Spine Surgery
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Physical Therapy
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Dry Needling
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Chiropractic Care
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Psychological Therapy
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Brace Support
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Acupuncture
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Hot/Cold Packs
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Massage Therapy
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TENS Unit
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Injections (Describe)
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Injections Description
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Please list any surgical procedures you have had done in the past including date
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I have NEVER had any surgical procedures performed
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Which of the procedures listed above have helped with your pain?
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Mark the following physicians or specialists you have consulted for your current pain problem(s)
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Please list the names of other health care providers you have seen for this condition
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Body Systems Review (Please check all that apply to you.)
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Cancer/Oncology
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Cancer Type
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Cardiovascular/Hematologic
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Gastrointestinal
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Urological
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Neurological
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Respiratory
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Musculoskeletal/Rheumatologic
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Psychological
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Endocrinology
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Diabetes
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Diabetes Type
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Other Diagnosed Conditions
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Social/Family History
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Describe your physical activities/exercise, including frequency & level of interest (hobby, amateur, competitive, professional)
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Occupation
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Have you been diagnosed with a mental health condition?
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How many hours of sleep do you get a night?
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How is your sleep quality?
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Are there any stairs in your current home?
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How many stairs?
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Are you currently receiving Workers’ Compensation?
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Is there an ongoing lawsuit related to your visit today
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Alcohol Use
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Caffeine
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Type?
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Tobacco Use
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Never Used
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Current User
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Former User
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Packs per day?
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Packs per day?
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How many years?
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How many years?
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Quit Date
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Other drug use
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Other drug use and frequency of use
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Are you currently taking any blood thinners or anti-coagulants?
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If YES, which ones?
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Do you have any implants in your body?
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Are you pregnant?
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Please list all medications you are currently taking including vitamins and supplements. Medication / Name / Dose / Frequency
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Please list all past-pain medications you have taken at any point for the current pain complaint. Medication/Name/Dose/Frequency
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Please list all allergies
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Mark all appropriate diagnoses as they pertain to your parents and siblings
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Other Medical Problems
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