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Select One (New Injury or Existing Injury)
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INITIAL VISIT: New Injury (New or Current Patient)
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FOLLOW UP VISIT: Existing Injury (Current Patient Only)
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New Injury Paperwork
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Will take 10-15 minutes to complete
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PLEASE TURN OFF ALL ADBLOCKING SOFTWARE TO ALLOW FORMS TO SAVE
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* indicates required question
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* Where did you find us?
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Who referred you?
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Are you currently seeing any other specialist?
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Other Specialist(s)
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CURRENT ISSUE & MEDICAL HISTORY
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* Initial / Chief Comlaint:
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* Injury is located on:
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* Please describe your injury:
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* Please describe your visit goals:
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* How did your injury happen?
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* When did your present symptoms start?
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* Do you avoid activities in fear of them causing pain?
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* Do you worry that your pain will never go away?
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Daily, my pain is present:
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Describe how your pain feels:
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* Rate your CURRENT level of pain/discomfort (0= NO PAIN, 10= WORST PAIN EVER)
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Rate your level of pain/discomfort when it feels BEST(0= NO PAIN, 10= WORST PAIN EVER)
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Rate your level of pain/discomfort when it feels WORST(0= NO PAIN, 10= WORST PAIN EVER)
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* How much does your pain interfere with sleeping?
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Other Symptoms:
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My pain radiates/shoots: (Please describe)
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I have experienced/am experiencing numbness/tingling: (Please Describe)
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* What best relieves your pain?
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Other please specify
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* What makes your pain worse?
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Other please specify
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HISTORY OF PRIOR TREATMENT FOR CURRENT INJURY
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* Have you had prior treatments for THIS injury?
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IF YES, select this box:
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Prior Surgeries
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Doctor Seen
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Explain
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Specialist Seen
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Doctor Seen
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Explain
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Recent Hospitalization
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Doctor Seen
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Explain
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Been Advised to Have Surgery
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Doctor Seen
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Explain
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Prior PT or Chiropractor
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Doctor Seen
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Explain
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Diagnostic tests done for THIS injury? (MRI, XRAY, etc)
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* Diagnostic tests done for THIS injury?
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IF YES, select this box:
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MRI - Findings of the tests
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Where / Date
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X-ray - Findings of the tests
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Where / Date
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CT Scan - Findings of the tests
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Where / Date
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Bone Scan - Findings of the tests
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Where / Date
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Bone Density - Findings of the tests
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Where / Date
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Nerve Conduction Test - Findings of the tests
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Where / Date
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CURRENT MEDICATIONS
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* Have you have taken OR are you presently taking any medications for THIS injury?
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IF YES, select this box:
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Pain Medication - Medication and Dosage
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Prescribing Doctor
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Anti - Inflammatory - Medication and Dosage
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Prescribing Doctor
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Muscle Relaxers - Medication and Dosage
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Prescribing Doctor
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Steroids - Medication and Dosage
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Prescribing Doctor
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Other - Medication and Dosage
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Prescribing Doctor
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REVIEW OF SYSTEMS (Experienced in Last Six Months)
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* Neurologic
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Other please specify
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* Respiratory
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Other please specify
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* Endocrine / Thyroid / Hormones
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Other please specify
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* Eyes / Ears / Nose / Throat
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Other please specify
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* Gastrointestinal
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Other please specify
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* Genitourinary
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Other please specify
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* Cardiovascular
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Other please specify
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* Musculoskeletal / Other
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Other please specify
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* Skin / Integumentary
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Other please specify
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For Women Only
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Last OBGYN Visit?
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Any complications, issues, problems, or additional information from the visit?
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Number of Pregnancies
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Number of Births
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Number of Children
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Any Difficulties?
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Are you currently Pregnant?
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Any additional information about difficult pregnancies, delivery complications, and/or menstrual problems?
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Breast: Positive Mammogram - Findings
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PAST FAMILY / SOCIAL HISTORY / OTHER MEDICATIONS
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MEDICATIONS
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* Are you currently taking any medication for OTHER health issues?
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IF YES, select this box:
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Antidepressants - Medication and Dosage
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Prescribing Doctor
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Allergy - Medication and Dosage
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Prescribing Doctor
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Blood Thinners - Medication and Dosage
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Prescribing Doctor
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Cardiac - Medication and Dosage
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Prescribing Doctor
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Cholesterol - Medication and Dosage
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Prescribing Doctor
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Thyroid - Medication and Dosage
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Prescribing Doctor
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Diabetes - Medication and Dosage
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Prescribing Doctor
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Hypertension - Medication and Dosage
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Prescribing Doctor
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Other - Medication and Dosage
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Prescribing Doctor
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ALLERGIES
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* Do you have any Allergies?
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Drug (Please Specify)
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Food (Please Specify)
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Latex (Please Specify)
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Seasonal (Please Specify)
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Other (Please Specify)
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SOCIAL HISTORY
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* Hobbies / Interests
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Sports or Other Physical Activities
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* Have you ever smoked cigarettes / vaped?
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If yes, how many packs daily
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If you quit, what year?
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* Do you drink alcohol beverages?
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If yes, how many drinks per week?
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Any additional medical conditions or surgeries that you have not already listed?
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Existing Injury Paperwork
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Update EACH Visit
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* Since last visit, Please describe your injury:
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* Since last visit, how do you feel overall?
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* CURRENT pain level
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Since last visit, my pain frequency has been:
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Since last visit, pain level at its BEST:
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Since last visit, pain level at its WORST:
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Since last visit, my pain occurs:
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Currently my pain feels:
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Since last visit, my pain feels BETTER with:
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Pain is also better with
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Since last visit, my pain feels WORSE with:
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Pain is also worse with
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Since last visit, my pain radiates to:
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Since last visit, I have felt numbness/tingling in:
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Other Comments
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