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