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PERSONAL INFORMATION |
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* Required fields |
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Name: |
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First:
MI:
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Last:
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Home Address: |
Street:
City:
State:
Zip: |
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Home Phone: |
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Cell Phone: |
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Place of Employment: |
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Work Address: |
Street:
City:
State:
Zip:
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Work Phone:
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Spouse, Guardian or Nearest Relative: |
Indicate relationship of secondary contact:
Spouse
Guardian
Nearest Relative
Relative's Name:
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Relative's Address:
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Check if same as above.
Street:
City:
State:
Zip:
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Relative's Phone: |
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Your Age: |
Age:
D.O.B.
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PATIENT QUESTIONNAIRE 1 |
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My chief problem is: |
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This has been
going on for: |
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Ever since: |
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Describe location of pain: |
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Describe nature of pain: |
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Location and description of numbness or tingling: |
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Location and description of weakness: |
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How have these symptoms changed your life, or your ability to perform your usual functions? |
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PATIENT QUESTIONNAIRE 2 |
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What makes these symptoms better? |
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What makes these symptoms worse? |
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What have you tried for these symptoms? |
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Do you have incontinence? |
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Do you have trouble walking? |
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Do you have other medical problems? |
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Have you ever had surgery? |
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PATIENT QUESTIONNAIRE 3 |
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What medicines, vitamins, herbs or supplements do you take? |
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Do you have allergies to any medications? |
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Do medical problems run in your family? |
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Do you smoke?
If so, how much & how long? |
Yes
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Do you drink alcohol?
If so, how much & how long? |
Yes
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What is your weekly activity list like? (i.e. list exercises, physical activity, etc) |
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Are your symptoms related to a work-related injury? |
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PATIENT QUESTIONNAIRE 4 |
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Aside from the problem from which you are seeking help from me, do you have any of the following (please check the item(s) and explain below):
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General/Constitutional |
Fevers
Chills
Nausea
Vomiting
Lethargy
Fast or slow heart beat
Lapses of consciousness
Lapses of memory |
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Skin/Breasts |
Rashes
Lumps under the skin
Easy Bruising
Easy Bleeding |
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Eyes/Ears/Nose/
Throat/Mouth |
Sore Throat
Difficulty swallowing or getting food down
Stuffed nose or sinuses
Hoarseness |
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Cardiovascular |
Chest pain
Skipped of irregular heart beats |
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Respiratory |
Trouble breathing
Frequent coughing
Production of sputum
Blood in sputum |
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Gastrointestinal |
Bloating
Abdominal pain
Pain after eating
Trouble with bowel movements |
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Genitourinary |
Trouble starting or stopping urine flow
Leakage of urine
Impotence
Incontinence
Blood in the urine or burning on urination |
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Musculoskeletal |
Pain in the joints
Limitation of range of motion
Cramping in the muscles |
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Neurological/Psychiatric |
Problems controlling mood
Loss of appetite
Sleepiness
Sleeping too much
Not sleeping enough
Trouble with balance or walking
Problems with vision, hearing, taste or smell |
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Allergic/Immunologic/
Lymphatic/Endocrine |
Swollen lymph glands
Frequent infections or illnesses
Milk from the breasts |
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Please explain: |
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PATIENT QUESTIONNAIRE 5 |
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What tests, Xrays, MRI's have you had? |
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Your primary physician is: |
Name:
Address:
City:
State:
Zip:
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Your referring physician is: |
Name:
Address:
City:
State:
Zip:
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