Please attach medical records as appropriate. ______
Concern (Please rank by priority)Example: (headaches) / Onset
(June 1978) / Frequency
(4 times/wk) / Severity
mild/mod/severe
1.
2.
3.
4.
5.
6.
What are your goals for this visit? ______
______
______
What aspect of your pain, or which pain is the most bothersome to you?
______
Pain Intensity:
On a scale of 1-10 with “0” representing no pain, “1” representing a nuisance which would not interfere with daily activities while “10” would be the most severe pain imaginable, which number best describes your pain?
What is your worst pain?0 1 2 3 4 5 6 7 8 9 10
Overall average pain?Less pain0 1 2 3 4 5 6 7 8 9 10More pain
What is your pain like today?0 1 2 3 4 5 6 7 8 9 10
How many extremely bad days (horrible or excruciating pain) in a week do you experience?______
Check the box which best gives the intensity of your type of pain:
Mild Moderate SevereUnbearableLocation
1. Sharp ______
2. Shooting ______
3. Throbbing ______
4. Cramping ______
5. Stabbing ______
6. Gnawing ______
7. Hot Burning ______
8. Aching ______
9. Heavy ______
10. Tender ______
11. Splitting ______
12. Tiring/Exhausting ______
13. Sickening ______
14. Fearful ______
15. Punishing/Cruel ______
How much time during an average day (24 hour period) are you in pain?
Pain is not present daily Less than 1/3 of the time Almost 50% of the time
Almost 2/3rds of the time Almost 24 hours Anytime that I am not laying down
Do any of the following make your pain change?
No Somewhat A Lot Somewhat Complete
ChangeWorseWorseBetterRelief
1. Sitting
2. Standing
3. Walking
4. Bending forward
5. Bending backward
6. Bending to same side
7. Bending to opposite side
8. Lying Down/Resting
9. Driving
10. Lifting
11. Coughing/Sneezing
12. Cold weather
13. Damp weather
14. Sexual activity
15. Overhead activity
16. Other______
Are you able to perform any of the following without assistance?
1.Walk Yes No4. Climb Stairs Yes No
2.Sit Yes No5. Dress Self Yes No
3.Stand Yes No6. Drive Car Yes No
Please mark the box which best describes the changes in your desire to participate in the following activities since the onset of your pain?
No Decreased Decreased
IncreasedChangeSome Quite a Bit Disappeared
Personal Hygiene
Household cleaning
Family activities
Recreation and hobbies
Sexual relations
Physical exercise
Watching television
How often do you have to stop your activities and sit down or lie down to control your pain?
Rarely (not daily) Approximately once a day Several times a day
I spend almost all day lying or sitting down to control my pain
Sleep Pattern
1. Has your sleep pattern changed due to pain? Yes No
2. Do you have trouble falling asleep? Yes No
3. How many times do you wake up at night? ______How many nights a week? ______
4. How many hours do you actually sleep?______
5. How do you feel when you wake up in the morning? ______
6. Do you take sleep aids? Yes NoIf so, what?______
Previous treatments for this pain complaint and where:
Chiropractor ______ Physical Therapy ______
Psychotherapy ______ Epidurals ______
Nerve Blocks ______ Cortisone Injections ______
Oral Cortisone ______ Operations______
Other ______
Previous Studies:
X-Rays CT Scan MRI Myelogram Bone Scan Nerve Conduction Study
Other ______
Prior experiences you have had with alternative medicine? ______
______
Are you involved with any other therapies such as massage, acupuncture, chiropractic now? Previously?
______
What medications are you taking now? (Include prescription and over-the-counter drugs)
MedicationReasonWhen StartedDosage per DayCost
______
______
______
______
______
______
______
Medication Side Effects:ConstipationSwelling Sweating Sleepiness Other: ______
Allergic reactions to medications
MedicationReaction/Intolerances
______
______
______
Allergic reactions to chemicals/substances
Chemical/SubstanceReaction/Intolerances
______
______
______
What vitamins/mineral/supplements are you taking now?
Brand or Other NameReasonWhen StartedDosage per DayCost
(manufacturer)
______
______
______
______
______
______
______
What physical activity do you participate in? ______
______
What are the major stressors in your life? ______
______
What do you do to relax? ______
______
Past Operations
WhatWhenWhatWhen
______
______
______
______
Past Family Medical History
FatherMotherGrandparents SiblingsChildren
Heart Disease _____ _____ ___________ _____
Hypertension _____ _____ ___________ _____
Cancer _____ _____ ___________ _____
Diabetes _____ _____ ___________ _____
Lung Disease _____ _____ ___________ _____
Hepatitis _____ _____ ___________ _____
Digestive _____ _____ ___________ _____
Seizures _____ _____ ___________ _____
Thyroid Disease _____ _____ ___________ _____
Other ______ _____ _____ ___________ _____
Other ______ _____ _____ ___________ _____
Other ______ _____ _____ ___________ _____
Occupation
______
Are you presently working? Yes No
What interests/hobbies do you have? ______
With whom do you live? (Include roommates, friends, partner, spouse, children, parents, relatives, pets)
NameAgeRelationshipNameAgeRelationship
______
______
______
______
Tobacco Never used Smoked from age _____ to ____. ____ packs per day.
Alcohol Never used Estimated drinks per day ____.
Other Drugs Never used Frequency ____.
What other things would you like us to know? ______
______
______
Who would you like us to send a consultation report to? ______
______
REVIEW OF SYSTEMSCheck symptoms you currently have.
GENERAL / RESPIRATORY / MUSCLE/JOINT/BONE / BLEEDING PROBLEMS
❑Chills / ❑ Shortness of breath / Pain, Weakness/Numbness: / ❑ On blood thinners
❑ Depression/Nervousness / ❑ Wheezing / ❑Neck ❑Chest / ❑ On platelet inhibitors
❑ Dizziness/Fainting / ❑ Short winded at rest / ❑ Arms ❑ Hands / ❑ Free bleeding with injury
❑ Fever / ❑ Short winded w/activity / ❑ Back ❑ Shoulders / ❑Known anemia
❑ Forgetfulness / ❑Chest pain with breathing / ❑ Hips ❑Knees
❑ Headache / ❑ Legs ❑Feet / GENITO-URINARY
❑ Loss of sleep / CARDIOVASCULAR / ❑ Blood in urine
❑ Loss of weight / ❑ Chest pain / NERVOUS SYSTEM / ❑ Frequent urination
❑ Numbness / ❑ High/Low blood pressure / ❑Numbness / ❑ Lack of bladder control
❑ Sweats / ❑ Irregular/Rapid heart beat / ❑ Tingling / ❑ Painful urination
❑ Poor circulation / ❑Upper extremities / ❑ Scars
ENDOCRINE / ❑Swelling of ankles / ❑Lower extremities / ❑Sore that won't heal
❑Excessive eating / ❑ Varicose veins / ❑Convulsions
❑ Excessive drinking / ❑Falls/near falls / MEN ONLY
GASTROINTESTINAL / ❑Clumsiness / ❑ Erection difficulties
ALLERGY & IMM / ❑Poor appetite / ❑ Lump in testicles
❑Allergic rhinitis / ❑ Bloating / PHYSCHIATRIC / ❑ Penis discharge
❑ Sensitivity to dander/ / ❑ Bowel changes / ❑Anxiousness / ❑ Sore on penis
pollen/food / ❑ Constipation / ❑Stress / ❑Prostate Problems
❑Hives / ❑ Diarrhea / ❑Depression / ❑ Other
❑ Excessive thirst / ❑ Suicidal thought
EYE, EAR, NOSE, THROAT / ❑ Gas / ❑ Alcohol/Drug abuse / WOMEN ONLY
❑ Bleeding gums / ❑ Hemorrhoids / ❑ Insomnia / ❑ Abnormal pap smear
❑ Blurred vision / ❑ Indigestion / ❑Memory loss / ❑ Bleeding between periods
❑ Crossed eyes / ❑ Nausea / ❑ Breast lump
❑ Difficulty swallowing / ❑ Rectal bleeding / SKIN / ❑ Extreme menstrual pain
❑ Double vision / ❑Stomach pain / ❑ Bruise easily / ❑ Hot flashes
❑ Earache/Ear discharge / ❑ Vomiting / ❑ Hives / ❑ Nipple discharge
❑ Hay fever / ❑ Vomiting blood / ❑ Itching/rash / ❑ Painful intercourse
❑ Hoarseness / ❑ Change in moles / ❑ Vaginal discharge
❑ Loss of hearing / ❑ Scars / ❑ Other
❑Sore that won't heal
Check if you have had in the past or presently have any of the following conditions:
❑Appendicitis / ❑Diabetes / ❑ Liver Disease / ❑Rheumatic Fever
❑Arthritis / ❑Emphysema / ❑Measles / ❑Scarlet Fever
❑Asthma / ❑Epilepsy / ❑Migraine Headaches / ❑Stroke
❑Bleeding Disorders / ❑ Glaucoma / ❑Multiple Sclerosis / ❑Thyroid Problems
❑Cancer / ❑Heart Disease / ❑Mumps / ❑Tuberculosis
❑Cataracts / ❑ Hepatitis / ❑Pacemaker / ❑Ulcers
❑Chemical Dependency / ❑Herpes / ❑Pneumonia / ❑Venereal Disease, HCV,
❑Chicken Pox / ❑Kidney Disease / ❑Polio / HBV, HIV, Other
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