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New Patient Packet
Name Account # Date HISTORY OF ILLNESS/INJURY/PAIN LOCATION Chief complaint and its location: TIMING & DURATION How often do you experience this pain? Constant Frequent Intermittent What caused the onset? (Please list your most recent incident (minor or major) that prompted this visit.) Occasional Date of onset? SEVERITY On a scale of 0 to 10 with 0 representing no pain & 10 being the most severe pain imaginable, use the key below to rate the severity of your pain. 0 = None 4 = Mild to Moderate 8 = Severe, Limits Most Activity 1 = Minimal 5 = Moderate 9 = Very Severe 2 = Very Mild 6 = Moderate to Severe 10 = Excruciating 3 = Mild 7 = Mildly Severe, Restricts Some Activity Sitting here today, right now, what is the intensity of your pain on a scale of 0 to 10? What is the least intense the symptom has been on a scale of 0 to 10? What is the most intense the symptom has been on a scale of 0 to 10? ASSOCIATED SIGNS & SYMPTOMS Please check those that apply Inflexibility Stiffness Spasms Cramps If this pain radiates or travels, please identify where to: QUALITY How would you best describe the sensation of the pain/symptom: Sharp Stabbing Aching Pins & Needles Pounding Shooting Burning Dull Tingling/Numb Throbbing Crawling Stinging MODIFYING FACTORS What aggravates the pain/symptom? Sneezing Lifting Exercising Looking up/down Walking Coughing Sitting Stooping Looking side/side Standing Stress Driving Getting out of bed Pushing Pulling Carrying Straining at BM Climbing stairs Getting in/out of car Repetitive movement Other: Doctor Signature: Patient Signature: Page 1 of 4 Name Account # Date What relieves this pain/symptom? Resting Sleeping Lifting Exercising Looking up/down Shower Advil Stooping Looking side/side Mineral Ice Over the past weeks/months this complaint is: Improving Getting worse About the same Have you seen anyone for this condition? Yes Other: No Whom? How did you hear about us? SECONDARY COMPLAINT & LOCATION THIRD COMPLAINT & LOCATION Location: Location: • Sitting here today, right now, what is the intensity of your pain on a scale of 0 to 10? • What is the least intense the symptom has been on a scale of 0 to 10? • What is the most intense the symptom has been on a scale of 0 to 10? • Sitting here today, right now, what is the intensity of your pain on a scale of 0 to 10? • What is the least intense the symptom has been on a scale of 0 to 10? • What is the most intense the symptom has been on a scale of 0 to 10? ASSOCIATED SIGNS & SYMPTOMS ASSOCIATED SIGNS & SYMPTOMS Please check those that apply Please check those that apply Inflexibility Stiffness Spasms Cramps Inflexibility Stiffness Spasms Cramps If this pain radiates or travels, please identify where to: If this pain radiates or travels, please identify where to: QUALITY QUALITY How would you best describe the sensation of the pain/ symptom: How would you best describe the sensation of the pain/ symptom: Sharp Stabbing Aching Sharp Stabbing Aching Pins & Needles Pounding Shooting Pins & Needles Pounding Shooting Burning Dull Tingling/Numb Burning Dull Tingling/Numb Throbbing Crawling Stinging Throbbing Crawling Stinging Over the past weeks/months this complaint is: Improving Getting worse Over the past weeks/months this complaint is: About the same Improving Getting worse About the same KEY VALUE QUESTIONS 1. What is your pain keeping you from doing that is most important in your life? 2. What do you enjoy doing most in your life? NOTES/COMMENTS: Doctor Signature: Patient Signature: Page 2 of 4 Name Account # Date Please place a checkmark by the condition that applies to you: • P = Present • N = Not present • PP = If it has ever been present in the past P N PP P N PP P N PP P N PP Fatigue Irritability Joint Stiffness Seizures Fever Depression Spinal Curvature Dizziness Chills Memory Loss Back Pain Tremors Night Sweats Headache Hot Joints Loss of Sensation Fainting Muscle Pain Joints Swelling Loss of Coordination Nervousness Muscle Weakness Stiff Neck Paralysis Concentration Loss Muscle Cramps Lumps/Masses Difficulty of Speech • P = Present • N = Not present • PP = If it has ever been present in the past • Do the same for your family Family History Key: F = Father • M = Mother • B = Brother • S = Sister • GF = Grandfather • GM = Grandmother P N PP Past Problem When and Explanation of Condition F M B S GF GM Cancer Stroke Thyroid Problems Asthma Heart Attack HIV Angina/Chest Pain Diabetes Arthritis Other Do you have a pacemaker? Yes No Are you pregnant? Yes No Do you think you may be pregnant? Yes No FOR DOCTOR'S USE ONLY - PATIENT PLEASE PROCEED TO PAGE 4 Allergic/Immunologic Genitourinary Cardiovascular Hematological/Lymphatic Constitutional Integumentary Ears/Nose/Mouth Musculoskeletal Endocrine Neurological Eyes Psychiatric Gastrointestinal Respiratory All other system reviews negative NOTES/COMMENTS: Doctor Signature: Patient Signature: Page 3 of 4 Name Account # Date PLEASE LIST PAST SURGERIES 1. Year 2. Year 3. Year 4. Year 5. Year 6. Year List any other key slips, falls or accidents you've had from childhood to present: Have you ever taken? 1. Date Insulin Yes No Year 2. Date Cortisone Yes No Year 3. Date Thyroid medicine Yes No Year 4. Date Male/Female Hormones Yes No Year 5. Date Blood Pressure Yes No Year Tranquilizers/Sedatives Yes No Year Birth Control Yes No Year What medications are you currently taking? 1. Date 2. Date Yes No Year 3. Date Yes No Year 4. Date 5. Date 6. Date Hospitalizations: OTHER INFORMATION Marital Status: Married Number of Children: Divorced Single Separated Married Regularly Children's Name(s): Frequency of Exercise: Never Rarely Occasionally Moderately Intensity of Exercise: Low Level Medium Level High Level Competition Level Sufficient Rest: Never Rarely Occasionally Moderately Hours of Sleep: Six Eight Ten More than 10 Well balanced diet: Never Rarely Occassionally Moderately Yes No Have you ever used street drugs? No Occasionally 1 to 2 2 to 3 4 to 5 More than 5/day Do you smoke? Do you drink caffeinated beverages? Do you drink alcohol beverages? Hobbies: NOTES/COMMENTS: Patient history was obtained from: Patient Doctor Signature: Father Son Mother Daughter Patient Signature: Page 4 of 4
