South Hills Spine & Extremity Center
ABOUT YOU:
Name ______Age ______Date of Birth______Date ______
Address ______City ______State_____ Zip______
Phone (Home) ______(Cell) ______Sex: M F Marital Status: S M D W
Social Security # ______-______-______Driver’s License #______-______-______
Work Status: Working w/o restriction Working with restrictions Not working
Occupation/ Employer ______Phone (Work)______
Work Address______City______State______Zip______
I will be paying for the services myself
Please bill: Health Insurance Auto Insurance Workers Compensation Other______
Insurance Company______Phone______
Insurance Company Address______City______State______Zip______
Insured’s Name ______Insured’s Date of Birth ______
Insured’s ID. # or S.S. # ______-______-______Insured’s Relationship to You______
Emergency Contact: Name______Phone (Home)______(Cell)______
Present condition due to an injury? Yes No On the Job Auto Accident Other ______
Has the accident been reported? Yes No To Employer Auto Carrier Other ______
How did you hear about us?______
HEALTH REPORT:
Give a brief detailed description of the problem you are currently experiencing: ______
What seemed to be the initial cause?______
How long have you had this condition?______Is it getting worse? Yes No
Have you had this problem previously? Yes No If yes, explain:______
What activities aggravate your condition/pain?______
What activities lessen your condition/pain?______
Is this condition worse during certain times of the day? Yes No If yes, when?______
Is this condition interfering with Work Sleep Routine Other ______
Please circle degree of pain, 0 none, 10 severe pain.
1. My pain when it is at its worst is:
No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst Possible
2. My pain currently is:
No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst Possible
3. My average pain level is:
No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst Possible
Using the symbols below, mark on the pictures where you feel pain.
Numbness = = =
Dull Ache OOO
Burning XXX
Sharp/Stabbing / / /
Pins, Needles + + +
Other ______^ ^ ^
HEALTH HISTORY: Name:______DOB ___/___/___
What treatment have you already received for this condition? Medication Surgery Physical Therapy Chiropractic None Other ______
Name and address of other doctor(s) that have treated you for this condition ______Date of last:
Physical exam______Spinal exam______Spinal X-ray______Urine test______Chest X-Ray______MRI, CT Scan, Bone Scan______Blood test______
Please check each item below for each sign or symptom you have or have had in the past and indicate the date.
General Gastrointestinal Cardiovascular Check any of the conditions
Allergies Abdominal pain High blood pressure you have or have had:
Depression Bloody or tarry stool Low blood pressure Alcoholism
Dizziness Colitis/ Crohn’s Hardening of the arteries Anemia
Fainting Colon trouble Irregular pulse Appendicitis
Fatigue Constipation Pain over heart Arteriosclerosis
Fractures Diarrhea Palpitation Asthma
Headaches Difficult digestion Poor circulation Bronchitis
Loss of sleep Diverticulosis Rapid heart beat Cancer
Mental illness Bloated abdomen Slow heart beat Chicken pox
Tremors Excessive hunger Swelling of ankles Cold sores
Weight loss/gain Gallbladder trouble Diabetes
Hernia Respiratory Eczema
Muscle/ Joint Hemorrhoids Chest pain Emphysema
Arthritis/ rheumatism Intestinal worms Chronic cough Epilepsy
Bursitis Jaundice Difficulty breathing Goiter
Foot trouble Liver trouble Hay fever Gout
Muscle weakness Nausea Shortness of breath Heart burn
Low back pain Painful defecation Spitting up phlegm/ blood Heart disease
Neck pain Pain over stomach Wheezing Hepatitis
Mid back pain Poor appetite Herpes
Joint pain Vomiting Women only High cholesterol
Vomiting or blood Congested breasts HIV/ AIDS
Skin Hot flashes Influenza
Boils Genitourinary Lumps in breasts Malaria
Bruise easily Bed-wetting Menopause Measles
Dryness Bladder infection Vaginal discharge Miscarriage
Hives or allergies Blood in urine Menstrual flow: Multiple sclerosis
Itching Kidney infection Reg. Irreg. Pain/ cramps Mumps
Rash Kidney stones Days of flow:____ Length of cycle ____ Numbness/tingling
Varicose veins Prostate trouble Date- 1st day of last period:______ Pace maker
Pus in urine Are you pregnant? Yes No Osteoporosis
Eye, Ear, Nose, & Throat Stress incontinence If yes, how many months? ______ Pneumonia
Colds Urination: How many children do you have?______ Polio
Deafness Overnight more than twice Birth control method:______ Rheumatic fever
Ear ache More than 8x in 24 hours Date of last PAP test:______ Stroke
Eye pain Decreased flow/force normal, abnormal Thyroid disease
Gum trouble Painful urination Date of last mammogram:______ Tuberculosis
Hoarseness Urgency to urinate normal, abnormal Ulcers
Nasal obstruction
Nose bleeds
Ringing of the ears
Sinus infection
Sore throat
Tonsilitis
Vision problems
SOCIAL HISTORY: Name:______DOB ___/___/___
Do you smoke cigarettes? Yes No If yes, how many years? _____ How many packs/day? ______
Do you use other types of tobacco? Yes No If yes, describe______
Do you drink alcohol? Yes No If yes, how many drinks/week? ______
How many hours/night do you sleep?_____ What position do you sleep in? R. side L. side Back Stomach
What thickness of pillow do you use? Thin Medium thickness Thick or >1 pillow
How would you rate your diet? Poor Average Good Very good
How would you describe your activity level? Sedentary Slightly active Active Very Active
How many cups of water do you drink per day? ______
Please list any medications that you are currently taking and why:______
______
______
Please list any vitamins/herbs/minerals/supplements that you are currently taking and why:______
______
______
FAMILY HISTORY: Please indicate if someone in your family has or has had the following:
HIV Positive Back problems Headaches Hypertension Thyroid disease Digestive problems
Stroke Asthma Heart disease Diabetes Emphysema Kidney disease
Osteoporosis Cancer Arthritis Seizures Mental illness Circulation problems
Liver problem
PAST INJURIES/SURGERIES: Description Date
Falls______
Head injuries______
Broken bones______
Dislocations______
Surgeries______
By signing below I attest that the information recorded above is accurate. I also attest that I have read and understand the information in the Notice of Privacy Practices form that was provided.
______
Patient’s Printed Name Today’s Date
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Patient’s Signature Parent/Guardian Signature