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Src patient history form

PINNACLE SPORTS PERFORMANCE AND REHABILITATION PATIENT HISTORY FORM
Name: ____________________________ Date: ____________________________
DOB: _________________________

Chief Complaint:

Pain in:  Head  Neck  Shoulder  Arm  Mid back FOR PROVIDER USE ONLY
 Low back  Buttock  Leg  Other__________________ History of Present Illness:
When did your pain begin?______________________  work-related?
 No apparent reason  Bending  Lifting  Fall Have you had a similar episode before?  Yes  No What have you been told is wrong? _____________________________
Prior tests for your pain:
Test/Results:
 X-ray______________________________________________________  MRI_______________________________________________________  CT________________________________________________________  Lab_______________________________________________________  Other______________________________________________________ Prior treatment for your current problem:
Anti-inflammatory:  Ibuprofen  Aleve Steroids:  Cortisone pills  Cortisone injection Injections:  Epidural  Facet  Other Spinal surgery:  Year/Procedures/Results__________________________ Physical therapy:  Year/Procedures/Results__________________________  Year/Procedures/Results__________________________ _____________________________________ Other Treatments:  Year/Type/Results _____________________________
How do the following affect your pain?

Please fill out the pain drawing below
Use these symbols on the drawings:
>>>> Ache
    Numbness
X X X X Burning
0 0 0 0 Pins and Needles
///////// Stabbing
What level would you rate your pain right now? (please circle)
None 0 1 2 3 4 5 6 7 8 9 10 Most severe
Family Medical History:  Heart disease  Cancer  Lupus  Diabetes
 Arthritis  Abnormal bleeding  Muscle disease  Scoliosis  Rheumatoid Arthritis  Drug allergies  Other ________________________ ____ Living parents? Mother  Yes  No; Died at age ______ of _____________ _____________________________________ Father  Yes  No; Died at age ______ of _____________ Name: __________________________
Date: ______________________________
DOB: _______________________

Current Work Status:
Employer ______________________________ Job Title________________________ Time at this position ______________________
 Regular Duty  Modified Duty - Date began:_____________________  Off work – Date began:____________________
Description of your Normal Job Activities

Standing
* If lifting at work, what is the average weight? ________________lbs. How many times per hour? __________________ Lifestyle Habits:
FOR PROVIDER USE ONLY
How long have you smoked? ________________ (years)  Alcohol _____ (# of drinks/day)  Caffeine beverages _______ (#/day) Are you currently exercising regularly?  Yes; how long: ______________  No; last regular exercise:__________ Has your condition prevented you from doing exercise?  Yes  No Past Medical History:
 Cancer  Arthritis  Alcoholism  Kidney disease   Glaucoma  Heart Disease  Tuberculosis  AIDS/HIV  Hepatitis  Diverticulitis  High Blood Pressure Surgeries/Hospitalizations:
Injuries/Fractures/Dislocations:
List all medications you are currently taking:
__________________
Drug Allergies: No Yes; ____________________________________

Review of Systems:
(Please check all that apply):
Ears, Mouth, and Throat:  Abrupt change in hearing  Difficulty swallowing  Urinary tract  Respiratory  Skin  Immune system dysfunction  Other ____________  Depression  Anxiety  Difficulty sleeping

Source: http://backtobhatt.com/data/docs/patienthistoryform.pdf

tamc.org

Procedure: Renal Scan Patient Name:_______________________________Date of Appointment:_________________________Time of Appointment:_________________________The Aroostook Medical Center would like you to have the best possible experience while you are in our care. Therefore, we have compiled information for you regarding your procedure. The following information has been provided in order

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