Whang – New Patient History Form
Name______Age _____ Date of Visit______
- What is your mainspinal problem or reason for today’s visit? (check all that apply)
□ Pain □ Spinal deformity □ Weakness □ Numbness □ Other ______
- When did your symptoms start and when was it severe enough to require medical attention?
Pain started______I first sought medical attention______
- If pain is a problem, where is the pain located? (check all that apply)
□ Neck □ Upper back □ Lower back □ Buttocks/thighs □ Right arm □Left arm □ Both arms
□ Right leg □Left leg □ Both legs □ Other ______
- Isthe pain worse in your extremities (arms/legs) or in your spine (back or neck)?
□ Worse in my extremities □ Worse in my spine □ Same in extremities and spine
- How severe is your pain? (circle the number corresponding to your average pain over the last week)
(No pain) 1 2 3 4 5 6 7 8 9 10 (Worst possiblepain)
- How would you describe your pain? (Check all that apply)
□ Sharp □ Shooting □ Achy □ Dull □ Burning □ Numbing □ Other ______
- Is your pain constant or intermittent? □ Intermittent □ Constant
- What makes the pain better? (Check all that apply)
□ Rest □ Lying down □ Sitting □ Standing □ Walking □ Medications □Nothing □ Other______
- What makes the pain worse? (Check all that apply)
□ Rest □ Lying down □ Sitting □ Standing □ Walking □Nothing □ Other______
- Do you have any weakness or numbness in your arms or legs?
□ None □ Weakness □ Numbness □ Weakness and numbness
- If so, which extremities are affected?
□ Right arm □Left arm □ Both arms □ Right leg □Left leg □ Both legs
- Have you noticed any changes in your coordination, balance, or walking?
□ None □ Coordination □ Balance □ Walking
- Are you losing bladder or bowel function (wetting or soiling yourself)? □ Yes □ No
- What treatments have you tried for your symptoms? (Checkall that apply and circle those that have helped)
□ Physical therapy □ Anti-inflammatory medications □ Other pain medications □ Epidural Injections (# ______)
□ Other injections □ Chiropractic manipulation □ Acupuncture □ Other______
- Are you taking medications for your pain? □ No □ Yes (please list) ______
______
- Are there any legal issues related to your spine? (Check all that apply)
□None □Workman’s compensation claim □ Accident claim □ Medical malpractice claim
Signature______Date ______
Name ______Age ______Date of Visit ______
List all of your diagnosed medical problems (not just spine related):
______
______
List all of the prior surgeries you have had (include the dates of the operations):
______
List all medications you are currently taking (including the doses):
______
List any medications that you are allergic to:
______
List any medical problems in yourfamily:
______
______
Do you smoke or use tobacco? □ Yes □ No
If so, how many years have you been smoking? ______How many packs do you smoke per day? ______
Do you use alcohol? □ Yes □ No If so, how many drinks per week? ______
Who do you live with? ______
Are you working? □ Yes □ No What is your profession or occupation?______
If you are not working, is it because of your spinal problem? ______
If you are not working, how long have you been out of work? ______
Signature ______Date ______
Patient Name______Date______
Please List any Symptoms or Problems you have in the Following Areas or Body Systems:
Constitutional
□ fevers
□ chills
□ night sweats
□ unintentional weight loss
□ other ______
Eyes
□ use of corrective eyewear
□ blurry vision
□ double vision
□ other ______
Cardiovascular
□ chest pains
□ irregular heart beat
□ enlarged heart
□ arrythmia
□ ankle swelling
□ heart attack
□ other ______
Respiratory
□ shortness of breath
□ cough
□ sputum production
□ asthma
□ other ______
Gastrointestinal
□ heart burn
□ ulcers
□ black stools
□ vomiting blood
□ other ______
Musculoskeletal
□ joint pains
□ joint swelling
□ muscle spasms
□ muscle weakness
□ trouble walking
□ other ______
Page 3
Skin
□ open sores
□ skin cancer
□ rashes
□ itching
□ other ______
Neurological
□ headaches
□ poor balance
□ trouble manipulating fine objects (e.g. buttons)
□ stroke
□ speech difficulties
□ other ______
Psychiatric
□ depression
□ suicidal thoughts
□ schizophrenia
□ bipolar disorder
□ difficulty handling your life’s stresses
□ other ______
Endocrine (hormones)
□ problems controlling blood sugar
□ problems with thyroid gland
□ abnormal hair growth
□ frequent or long-term steroid use
□ other ______
Hematologic
□ bleeding problems
□ easy bruising
□ use of aspirin or anti-inflammatory medications
□ use of coumadin, plavix or other blood thinners
□ anemia
□ other______
Genitourinary
□ burning with urination
□ trouble with intercourse
□ trouble with erections
□ menstrual problems
□ heavy periods
July/07.2