Body Chart Pain/symptoms

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:
Mark on the body chart where your pain/symptoms are for THIS injury
HEIGHT: _____________
WEIGHT: _____________
INJURY DATE/DATE OF ONSET: __________
REFERRED BY: _________________________
INJURY WAS/IS (CIRCLE ONE):
EMPLOYMENT AUTO OTHER _____________
:
Please check if you have ever had any of the following
_____ FRACTURES
_____ BACK INJURY
_____ NECK INJURY
_____ KNEE INJURY
_____ HEAD INJURY
_____ HEART DISEASE
_____ HYPERTENSION
_____ PACEMAKER
_____ STROKES
_____ SEIZURES
_____ LUNG DISEASE
_____ CIRCULATION PROBLEMS
_____ ASTHMA
_____ DIABETES
_____ HERNIA
_____ PNEUMONIA
_____ CATARACTS
_____ CANCER
Have you recently noted:
Yes/No Weight loss/gain
Yes/No Numbness/ tingling
Yes/No Fatigue
Yes/No Fever/chills/sweats
Yes/No Nausea/Vomiting
Yes/No Weakness
Please list any other diagnosis that you have had _____________________________________________________
_________________________________________________________
Please list any surgeries you have had: _____________________________________________________________
________________________________________________________________
Please list any medications you are currently taking: __________________________________________________
_______________________________________________________________________
Allergic to: ___________________________________________________________________________________
Do you have any metal implanted in your body? If so, where? ___________________________________________
If you are female, are you pregnant? __________________________
If you are over 65, have you fallen in the past year? _________________Were you injured? _______________
Do you:
Smoke? Yes/No __packs/day Drink Alcohol? Yes/No ___drinks/day Caffeinated beverages? ____/day
Other professionals you have seen, or are currently seeing for your present injury or illness.____________________
_____________________________________________________________________________________________
_____________________________________________________
_________________________
Patient Name
Date

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