Quickcharts Patient Case History Template (Page 2 of 3) in pdf

Quickcharts Patient Case History Template Page 2

Have you had any auto or other accidents? □No □Yes

Describe:______________________________________________________________________________

Date of last physical examination: _________________ Do you smoke? □No □Yes

Do you drink alcohol? □No □Yes - how many per day? _________________

Do you drink caffeine? □No □Yes - how many per day? _________________

Do you exercise? □No □Yes (what forms and how often): _______________________________________

PLEASE MARK YOUR AREAS OF PAIN ON THE DIAGRAM BELOW

Main reason for consulting the office:

□Become pain free

□Explanation of my condition

□Learn how to care for my condition

□Reduce symptoms

□Resume normal activity level

What is your major complaint? ____________________Date problem began? _____________________

How did this problem begin (falling, lifting, etc.)?______________________________________________

How is your condition changing? □GETTING BETTER □GETTING WORSE □NOT CHANGING

Have you had this condition in the past? YES - NO

How often do you experience your symptoms?

□Constantly (76-100% of the day) □Frequently (51-75% of the day)

□Occasionally (26-50% of the day) □Intermittently (0-25% of the day)

Describe the nature of your symptoms: □Sharp □Dull □Numb □Burning □Shooting □Tingling □Radiating

Pain □Tightness □Stabbing □Throbbing □Other: ______________________________________

Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain)

□1□2 □3 □4 □5 □6 □7 □8 □9 □10

How do your symptoms affect your ability to perform daily activities such as working or driving?

(0= no effect and 10= no possible activities) □1 □2 □3 □4 □5 □6 □7 □8 □9 □10

What activities aggravate your condition (working, exercise, etc)?________________________________

What makes your pain better (ice, heat, massage, etc)? __________________________________________

Quickcharts Patient Case History Template Page 2