New Patient History Form
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1
2NEW PATIENT HISTORY FORM
Patient Name: ______________________________________
Date of Birth: ______________ Date: ________________
Occupation: ________________________ Who referred you to our office/ PCP: ___________________________________
What are we seeing you for today? ______________________________________________________________________
Side:
LEFT
RIGHT
BOTH
When did your symptoms start (date)? _______________________
What are your expectations today? Explanation or diagnosis Tests Medication
Therapy Injection Surgery
Please check ONE box that best describes how your problem started:
No Injury- Onset was:
Gradual
Sudden Why do you think it started? _____________________________
Injury:
Accident
Sport
Work related
Worker’s compensation
Motor Vehicle Accident
Date of injury? ________
Sport? _____________
School? _______________
On a scale of 0-10 (0 is no pain, 10 is the worst) how would you rate your pain? (Circle) 0 1 2 3 4 5 6 7 8 9 10
Pain frequency:
Constant
Intermittent
Occasional
Rare
Since your problem started, it is:
Getting better
Getting worse
Unchanged
Quality of pain:
Aching
Burning
Dull
Sharp
Throbbing
Other: ________
What makes your symptoms worse? Bending Climbing Stairs Descending stairs Sitting Standing Lifting Movement
Pushing Walking Other: _______________________
What makes your symptoms better? Brace/Splint Elevation Exercise Heat Ice Injection
Massage OTC/ Rx Meds
Therapy
Rest
Stretching
Other: ____________________
Associated symptoms:
Bruising Crepitus Decreased mobility Instability Limping
Locking
Numbness
Popping
Spasms
Swelling
Tingling
Weakness
Nocturnal awakening
What was your most recent height: ____/____
Weight? ______
Medications (Please list all vitamins, supplements, and over the counter meds as well as prescription drugs):
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Allergies (Please list what type of reaction you had in addition to the name of the drug):
_____________________________________________________________________________________________________
Please list any previous surgeries and what year you had them: ________________________________________________
_____________________________________________________________________________________________________
Marital Status: Single Married Separated Divorced Widowed Smoking status: Never Quit – what year? _________
Smoker- How many per day? _____ Do you consume caffeine?
Never
Yes- What type? _________________________
Alcohol use: Never Rarely Moderate Daily Drug use:
Never
Yes- Type & Frequency?_________________________
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Parent category: Medical