Please take a moment to answer the following questions. Your responses will help meunderstand your problem and provide better care and treatment. All information is strictly confidential.
I. GENERAL PATIENT INFORMATIONDate: ____/____/_____
Name:
Address:
City, State, Zip Code:
Home Phone: Cell and/or Work Phone:
Email address:
Age: ______Date of Birth: _____/_____/______
Gender: M F Height: ____’____” Weight: _____ lbs. Marital Status:
Occupation: Employer:
Family Physician: Phone:
Insurance Company: Policy #:
How did you hear about our office?
Reason for visit ______
II. CURRENT STATUS
Please indicate on the figure below where your pain is now. Use the following symbols to indicate:
Ache > Numbness O OOPins/needles x xxStabbing //////
1. When did the current episode of pain begin?______
2. How did it occur?
gradual onset reaching lifting fall twisting pushing
direct blow bending pulling don’t know
3. Was your injury the result of one of the following?
Vehicle accident Recreational accident
On-the-job injury Non-work related incident No known cause
4. Briefly describe the onset of your pain and the events which preceded onset?
______
______
______
______
5. What do the following activities do to your pain?
No Change Relieves Pain Increases Pain After How Long?
Sitting ______
Walking ______
Standing ______
Lying down ______
Bending forwards ______
Bending backwards ______
Lifting ______
Coughing/Sneezing ______
Changing positions ______
6. What do you do to relieve your pain? ______
______
III. SEVERITY
- Please describe the pain: constant, comes and goes
sharp, dull, throbbing, aching, radiating, burning, cramping, stabbing, other
If other please describe ______
2. Do you have numbness, tingling, weakness, other (please specify) ______
3. Please rate your current level of pain according to the following Rating Scale:
Level 1-2 No problem sleeping, don’t need any pain medication
Level 3 Pain may wake you once or twice at night but you go right back to sleep
Level 4-6 Difficulty sleeping. You can walk, talk and drive. NSAID’sare necessary to cope with pain
Level 7 You need stronger medication to deal with the pain
Level 8-9 You are in the hospital for pain control. You have difficulty walking, talking and can’t drive
Level 10 You can’t talk or walk, breathing is difficult, you are barely able to stay alive
Pain Level today:
4. Over the past TWO weeks:
Please rate your worst pain. Please rate your least pain:
IV. TESTING
Have you had previous testing for this condition? Yes No If yes, please explain below:
Workup Date Results
X-rays ___/___/______
MRI ___/___/______
CT scan ___/___/______
EMG ___/___/______
Other ___/___/______
V. TREATMENT
1. Please check the boxes corresponding to the results you experienced with treatments you have tried:
Helped Made worse No effect Name of Doctor/Therapist
Physical Therapy ______
Hot packs ______
Ice packs ______
Ultrasound ______
Massage ______
Chiropractic treatment ______
Osteopathic manipulation ______
Trigger point injections ______
Epidural steroid injections ______
Acupuncture ______
Bed rest ______
VI. GENERAL HEALTH HISTORY
1. Who is your Primary care physician?
Name:______Phone:______
Address: ______
2. Do you have any medical problems and/orpast surgeries? Yes No If yes briefly describe:
Please include any hip or knee replacements, whether left or right joint and date of surgery. Also indicate whether you have had any back or neck surgeries.
______
______
______
______
______
3. Do you have a previous history of pain or discomfort in the area of you current complaint?
Yes No If yes please describe history and duration of this condition:
______
______
______
______
4. Do you take painmedications including herbs or supplements? Yes No
Name of Medication, Dosage, and how long have you been taking these?
______
______
______
5. Do you have anydifficulty sleeping due to this condition? Yes No If yes please describe:
______
______
6. Are you taking a blood thinning medication? Yes No If yes, name of drug:______
7. Do you have a pacemaker? Yes No
8. Circle the number to indicate the extent of problems you are having with each of the following:
None ModerateSevere
Anxiety12 3 4 5 6 7 8 9 10
Depression 12 3 4 5 6 7 8 9 10
Irritability 12 3 4 5 6 7 8 9 10
Insomnia12 3 4 5 6 7 8 9 10
9. Do you have a regular exercise program? Yes No If yes please describe:
______
______
10. Are you on a restricted diet: Yes No If yes please describe:
______
______
Please describe your Average Daily Diet:
BreakfastLunchDinner
Snacks (eaten at what times?):
11. How much water do you drink daily?
12. How many caffeinated drinks do you drink per day (coffee, tea, soda)?
13. Do you smoke? : Yes No If yes, how many cigarettes per day?
14. Usual Occupation:______
15. Does the condition you are presenting with prevent you from performing any of your duties at work?
Yes No If yes please describe:
______
______
16. Does the condition you are presenting with prevent you from performing any of your household duties? Yes No If yes please describe:
______
______
17. How physically demanding is your job?
Very heavy (frequently lifting >100 pounds) Heavy (frequently lifting >60 pounds)
Moderate (frequently lifting >30 pounds) Light (frequently lifting < 30 pounds)
Sedentary (essentially no lifting)
VII. SOCIAL HISTORY
1. Are you: Single Married/Partner Divorced Widowed Significant Other
2. Have you had a stress or change in a significant relationship within the past 12 months? Yes No
3. If you have children, what are their ages?______
3. If you have adult children, do they live nearby? Yes No
4. What is your highest level of education or training?
High School/GED Some college College Masters Doctorate Professional degree
5. Approximately how many alcoholic beverages do you drink each week? ______
6. Have you ever smoked? Yes No If yes, are you currently smoking? Yes No If yes, how many cigarettes per day? ______
7. Do you live in a: Apartment House with an elevator without an elevator
8. Are you required to climb stairs in your home? Yes No
9. Do you get around your house or community with a: cane walker wheelchair scooter no assistance required
VIII. FAMILY HISTORY
Please circle all that apply in your immediate family:
CancerDiabetesHigh Blood PressureStrokeSeizures Allergies Asthma Heart Disease Arthritis Rheumatoid Arthritis Neck pain Back Pain Knee pain
Other Major Illnesses:
Please describe any other problems you would like to discuss:
Patient Signature: ______Date: ______
Acupuncturist Signature: ______Date: ______