Name Today's Date * First Name: * Last Name: * Birthday: * Age: * Address * City: * State: * - Select Province/State -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ====================AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: * Email: * Cell Phone: Home Phone: Marital Status: * Single Married Do you have insurance: Yes No Work Phone: Social Security #: Driver's License #: Employer: Occupation: Spouse's Name: Spouse's Employer: Number of Children: 0 1 2 3 4 5+ Emergency Contact Name: Emergency Contact Number: History of Complaint: Primarily: Secondarily: Third: Fourth: On a scale of 0 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by choosing a number. Primary Compliant: 012345678910 Secondary Complaint: 012345678910 Third Complaint: 012345678910 Fourth Complaint: 012345678910 When did the problem(s) begin? When is the problem(s) at its worst? AM PM Mid-Day Late PM All the time How long does it last? It is constant. I experience it on and off during the day. It comes and goes throughout the week. How did the injury happen? Condition(s) ever been treated by anyone in the past? Yes No Which area of the body are you having problems? Choose all areas: (Back) Head Neck/Shoulders Upper Back Lower Back Hips Upper Legs Knees Lower Legs Feet Arms Which area of the body are you having problems? Choose all areas: (Front) Head Neck/Shoulders Torso Area Hips Upper Legs Knees Lower Legs Feet Arms What relieves your symptoms? What makes them feel worse? List Restricted Activity: Current Activity Level Usual Activity Level: Identify any other injury(s) to your spine, minor or major, that the doctor should know about:Past History: Have you suffered with any of this or a similar problem in the past? Yes No Other forms of treatment tried: Yes No Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body:If you have ever been diagnosed with any of the following conditions, please indicate with Past, Current, or Never. Broken Bone Past Current Never Heart Attack Past Current Never Dislocations Past Current Never Osteo Arthritis Past Current Never Tumors Past Current Never Diabetes Past Current Never Rheumatoid Arthritis Past Current Never Cerebral Vascular Past Current Never Fracture Past Current Never Disability Past Current Never Cancer Past Current Never Other Serious Conditions Past Current Never Please identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem: Injuries Surgeries Childhood Diseases Adult Diseases Social History: Smoking Cigars Pipe Cigarettes How Often Daily Weekends Occasionally Never Alcoholic Beverage Daily Weekends Occasionally Never Recreational Drug Use Daily Weekends Occasionally Never Family History: Does anyone in your family suffer with the same condition(s)? No Yes If Yes, Whom? grandmother grandfather mother father sister(s) brother(s) son(s) daugther(s) Have they ever treated for their conditions? No Yes I don't know Any other hereditary conditions the doctor should be aware of? No Yes Daily Activities: Effects of Current conditions on Performance. Please identify how your current conditions are affecting your ability to carry out activities that are routinely part of your life. Bending No Effect Painful (Can Do) Painful (limits) Unable to Perform Concentrating No Effect Painful (Can Do) Painful (limits) Unable to Perform Doing Computer Work No Effect Painful (Can Do) Painful (limits) Unable to Perform Gardening No Effect Painful (Can Do) Painful (limits) Unable to Perform Playing Sports No Effect Painful (Can Do) Painful (limits) Unable to Perform Recreation Activities No Effect Painful (Can Do) Painful (limits) Unable to Perform Shoveling No Effect Painful (Can Do) Painful (limits) Unable to Perform Sleeping No Effect Painful (Can Do) Painful (limits) Unable to Perform Watching TV No Effect Painful (Can Do) Painful (limits) Unable to Perform Carrying No Effect Painful (Can Do) Painful (limits) Unable to Perform Dancing No Effect Painful (Can Do) Painful (limits) Unable to Perform Dressing No Effect Painful (Can Do) Painful (limits) Unable to Perform Lifting No Effect Painful (Can Do) Painful (limits) Unable to Perform Pushing No Effect Painful (Can Do) Painful (limits) Unable to Perform Rolling Over No Effect Painful (Can Do) Painful (limits) Unable to Perform Sitting No Effect Painful (Can Do) Painful (limits) Unable to Perform Standing No Effect Painful (Can Do) Painful (limits) Unable to Perform Working No Effect Painful (Can Do) Painful (limits) Unable to Perform Climbing No Effect Painful (Can Do) Painful (limits) Unable to Perform Doing Chores No Effect Painful (Can Do) Painful (limits) Unable to Perform Driving No Effect Painful (Can Do) Painful (limits) Unable to Perform Performing Sexual Activity No Effect Painful (Can Do) Painful (limits) Unable to Perform Reading No Effect Painful (Can Do) Painful (limits) Unable to Perform Running No Effect Painful (Can Do) Painful (limits) Unable to Perform Sitting to Standing No Effect Painful (Can Do) Painful (limits) Unable to Perform Walking No Effect Painful (Can Do) Painful (limits) Unable to Perform Headache Past Current Never Pregnant (Now) Past Current Never Dizziness Past Current Never Prostate Problems Past Current Never Ulcers Past Current Never Neck Pain Past Current Never Frequent Colds/Flu Past Current Never Loss of Balance Past Current Never Impotence/Sexual Dysfun Past Current Never Heartburn Past Current Never Jaw Pain, TMJ Past Current Never Convulsions/Epilepsy Past Current Never Fainting Past Current Never Digestive Problems Past Current Never Heart Problem Past Current Never Shoulder Pain Past Current Never Tremors Past Current Never Double Vision Past Current Never Colon Trouble Past Current Never High Blood Pressure Past Current Never Upper Back Pain Past Current Never Chest Pain Past Current Never Blurred Vision Past Current Never Diarrhea/Constipation Past Current Never Low Blood Pressure Past Current Never Mid Back Pain Past Current Never Pain w/cough/sneeze Past Current Never Ringing in Ears Past Current Never Menopausal Problems Past Current Never Asthma Past Current Never Low Back Pain Past Current Never Foot or Knee Problems Past Current Never Hearing Loss Past Current Never Menstrual Problem Past Current Never Difficulty Breathing Past Current Never Hip Pain Past Current Never Sinus/Drainage Problme Past Current Never Depression Past Current Never PMS Past Current Never Lung Problems Past Current Never Back Curvature Past Current Never Swollen/Painful Joints Past Current Never Irritable Past Current Never Bed Wetting Past Current Never Kidney Trouble Past Current Never Scoliosis Past Current Never Skin Problems Past Current Never Mood Changes Past Current Never Learning Disability Past Current Never Gall Bladder Trouble Past Current Never Numb/Tingling arms, hands, fingers Past Current Never ADD/ADHD Past Current Never Eating Disorder Past Current Never Liver Trouble Past Current Never Numb/Tingling Legs, Feet, Toes Past Current Never Allergies Past Current Never Trouble Sleeping Past Current Never Hepatitis (A,B,C) Past Current Never List Prescription & Non-Prescription Drugs you take:
