Patient Medical History Form

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PATIENT MEDICAL HISTORY FORM (Continued)
Are you taking any medications presently? NO_____ YES_____ If so, please list:_______________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
13. Describe the nature of your problem and indicate on diagram where: ______________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please indicate your CURRENT pain level on the chart below:
|----------|----------|----------|----------|----------|----------|----------|----------|----------|----------|
0
1
2
3
4
5
6
7
8
9
10
No Pain
Moderate Pain
Worst Pain
14. What if any treatments have you had for this current problem? ___________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Did they help? Yes____ No____
15. What in particular makes your pain worse? ___________________________________________________________
__________________________________________________________________________________________________
16. What, if anything, eases the pain? __________________________________________________________________
17. Can you get comfortable at night? Yes___ No___
18. How do you feel upon rising? Stiff___ Sore___ Fine___
19. Once you start moving about, does it worsen____ or ease____?
20. What is it like at the end of the day? Worse___ Easier____
21. Do you have any pins and needles, etc? Yes___ No___ (if yes, please indicate location on diagram above)
22. At this time, do you consider you are getting better___, worse___ or stable___?
Please rate your ability to perform the following activities:
4-Can’t do at all
1-Not Limited 2-Can do with some difficulty 3-Can do with significant difficulty
Sleeping___
Dressing___
Sitting___
Standing___
Walking___
Housework___
Driving___
Stairs___
Sporting Activities___
Sexual Activity___
Yardwork___
WHAT GOALS DO YOU WANT TO ACHIEVE WITH THERAPY?______________________________________
__________________________________________________________________________________________________
WHERE DID YOU HEAR ABOUT US?_______________________________________________________________
Patient Signature:____________________________________
Date:__________________________________

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