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Please Read Each Option below and Select the one that best describes the reason for today's . Please be as detailed aspossible.
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Click here if you are a New Patient
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Please describe your Chief Complaint
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Was there a specific injury?
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If yes, Please describe injury (include dates)
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Has your pain/symptoms...
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How would you describe your pain/symtoms?
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Is the pain constant, intermittent or positional?
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What makes your pain worse?
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if other, please describe
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What helps relieve your pain/symtoms?
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if other, please describe
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Does the pain wake you up at night?
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Are you having any of the following symtoms?
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what physical activities, sports & hobbies do you typically enjoy and how have your symptoms affected these?
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Previous Treatment
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Have you tried any physical therapy?
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Did you have any relief?
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Please include dates of physical therapy treatment
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Have you tried any epidural injections?
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Did you have any relief?
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Please include dates of injections and physician name who performed injection
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Have you tried any chiropractic treatment?
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Did you have any relief?
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Please include dates of chiropractic treatment
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Have you tried any acupuncture?
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Did you have any relief?
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Please include dates of acupuncture treatment
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Do you have any of the following New Imaging to review with Dr. Khurana?
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Please list imaging facility most recent imaging was performed at
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Have you seen another surgeon?
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Have you seen a neurologist?
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Past Medical History
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Have you ever had any of the following? Please check all that apply
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if other, please describe
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Have you ever had spine surgery?
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If yes, please provide dates, type/levels of surgery and who performed the surgery
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Please describe Other Surgical History (Included date, type of surgery, and reason)
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Please list current Medications (Medication, Dosage, Frequency)
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Please List any Allergies and what type of reaction you have (If Applicable)
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Please List any significant Family History
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Social History
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Smoking Status
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Please enter how much per day or year quit
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Alcohol Status
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Please enter frequency/ year quit
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Illicit/Recreational Drug Use
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Please include frequency, year quit
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Height
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Weight
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Review of Symptoms- Please Select all that pertain to your current health
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Musculoskeletal
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General [+]
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HEMATOLOGIC/LYMPHATIC [+]
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Skin [+]
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Cardiovascular [+]
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HEENT [+]
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Respiratory [+]
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Gastrointestinal
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Genitourinary [+]
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FEMALES ONLY: Previous Pregnancies and/or Deliveries?
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Number of Pregnancies
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Number of Deliveries
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Endocrine [+]
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Neurological [+]
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Psychiatric [+]
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Click Here if you are a New Patient and were involved in a motor vehicle accident and are on a Lien (Attorney referred)
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Attorney Name/ Phone Number
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Date Of Accident
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Were you the driver?
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Were you wearing your seatbelt?
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Please describe details of the accident (Please include location of accident, approximate speed, direction of travel etc.)
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Did your airbags deploy?
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Did you hit your head or lose consciousness during the accident?
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Did an Ambulance arrive on scene?
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Did you go by ambulance to the Hospital?
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If yes, what hospital did you go to?
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What treatment was provided at the Hospital (if applicable)
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Prior to the accident, Did you have any pain in your back or neck?
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If yes, please describe
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Where is your pain currently located/current symptoms?
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Has your pain/symptoms...
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How would you describe your pain/symtoms?
• • •
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Is the pain constant, intermittent or positional?
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What makes your pain worse?
• • •
|
if other, please describe
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|
What helps relieve your pain/symtoms?
• • •
|
if other, please describe
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Does the pain wake you up at night?
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Are you having any of the following symtoms?
• • •
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What is your pain on a scale of 0-10? (0 being no pain, 10 being severe pain)
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Previous Treatment
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Have you tried any physical therapy?
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Did you have any relief?
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Please include dates of physical therapy treatment
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Have you tried any epidural injections?
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Did you have any relief?
|
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Please include dates of injections and physician name who performed injection
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Have you tried any chiropractic treatment?
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Did you have any relief?
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Please include dates of chiropractic treatment
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Have you tried any acupuncture?
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Did you have any relief?
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Please include dates of acupuncture treatment
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Do you have any of the following Imaging to review with Dr. Khurana?
• • •
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Please list imaging facility most recent imaging was performed at
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Past Medical History
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Have you ever had any of the following? Please check all that apply
• • •
|
if other, please describe
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Have you ever had spine surgery?
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If yes, please provide dates, type/levels of surgery and who performed the surgery
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Please describe Other Surgical History (Included date, type of surgery, and reason)
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Please list current Medications (Medication, Dosage, Frequency)
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Please List any Allergies and what type of reaction you have (If Applicable)
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Please List any significant Family History
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|
|
Social History
|
|
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Smoking Status
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Please enter frequency/ year quit
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Alcohol Status
|
Please enter frequency/ year quit
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Illicit/Recreational Drug Use
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Please include frequency, year quit
|
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Height
|
Weight
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Review of Symptoms- Please Select all that pertain to your current health
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|
Musculoskeletal
• • •
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General [+]
• • •
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HEMATOLOGIC/LYMPHATIC [+]
• • •
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Skin [+]
• • •
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Cardiovascular [+]
• • •
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HEENT [+]
• • •
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Respiratory [+]
• • •
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Gastrointestinal
• • •
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Genitourinary [+]
• • •
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Endocrine [+]
• • •
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FEMALES ONLY: Previous Pregnancies and/or Deliveries?
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Number of Pregnancies
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Number of Deliveries
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Neurological [+]
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Psychiatric [+]
• • •
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Click here if you are a New Patient with an active workers compensation case
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Please Enter Claim #
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Adjuster Name and Contact Information (Please include phone, email, address if you have it )
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What is your Work Status?
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Date of Injury
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Please describe Injury (include dates)
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Where is your pain currently located?
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Has your pain/symptoms...
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How would you describe your pain/symtoms?
• • •
|
|
|
Is the pain constant, intermittent or positional?
|
|
|
What makes your pain worse?
• • •
|
if other, please describe
|
|
What helps relieve your pain/symtoms?
• • •
|
if other, please describe
|
|
Does the pain wake you up at night?
|
|
|
Are you having any of the following symtoms?
• • •
|
|
|
Previous Treatment
|
|
|
Have you tried any physical therapy?
|
Did you have any relief?
|
|
Please include dates of physical therapy treatment
|
|
|
Have you tried any epidural injections?
|
Did you have any relief?
|
|
Please include dates of injections and physician name who performed injection
|
|
|
Have you tried any chiropractic treatment?
|
Did you have any relief?
|
|
Please include dates of chiropractic treatment
|
|
|
Have you tried any acupuncture?
|
Did you have any relief?
|
|
Please include dates of acupuncture treatment
|
|
|
Do you have any of the following Imaging to review with Dr. Khurana?
• • •
|
|
|
Please list imaging facility most recent imaging was performed at
|
|
|
Past Medical History
|
|
|
Have you ever had any of the following? Please check all that apply
• • •
|
|
|
Have you ever had spine surgery?
|
|
|
If yes, please provide dates, type/levels of surgery and who performed the surgery
|
|
|
Please describe Other Surgical History (Included date, type of surgery, and reason)
|
|
|
Please list current Medications (Medication, Dosage, Frequency)
|
|
|
Please List any significant Family History
|
|
|
Social History
|
|
|
Smoking Status
|
Please enter how much per day or year quit
|
|
Alcohol Status
|
Please enter frequency/ year quit
|
|
Illicit/Recreational Drug Use
|
Please include frequency, year quit
|
|
Height
|
Weight
|
|
Review of Symptoms- Please Select all that pertain to your current health
|
|
|
Musculoskeletal
• • •
|
|
|
General [+]
• • •
|
|
|
HEMATOLOGIC/LYMPHATIC [+]
• • •
|
|
|
Skin [+]
• • •
|
|
|
Cardiovascular [+]
• • •
|
|
|
HEENT [+]
• • •
|
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Respiratory [+]
• • •
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Gastrointestinal
• • •
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Genitourinary [+]
• • •
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FEMALES ONLY: Previous Pregnancies and/or Deliveries?
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Number of Pregnancies
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Number of Deliveries
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Endocrine [+]
• • •
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Neurological [+]
• • •
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Psychiatric [+]
• • •
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Click here if you are an Established Patient
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Where is your current pain/symptoms located?
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Do you have any of the following New Imaging to review with Dr. Khurana?
• • •
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Since your last appointment, have you had any of the following treatments?
• • •
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If Other, Please elaborate
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Did you have any relief with recent treatment?
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What medication are you currently taking for your pain/discomfort?
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What is your pain on a scale of 0-10? (0 being no pain, 10 being severe pain)
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Any specific questions or concerns you would like to discuss with Dr. Khurana at this appointment?
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Click Here if this is a Work Related Injury (Active Worker's Comp Case)
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What is your Work Status?
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Have you tried any acupuncture?
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