Name: _________________________________ DOB: _____/_____/______ Age: ______ Today’s Date: ____/_____/_____
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Right □ Left □Ambidextrous
Height: ____Weight: ____ Hand dominance
Primary Care Provider: __________________Who referred you to the office:_________________________________________
Name of School:_________________________Coach’s name:____________________Sport:____________________________
Is this a work injury with a Workers Compensation Claim? □Yes □No Claim Number:________ Litigation pending? □Yes □No
Name of attorney (if applicable)____________________________Phone #___________________________________________
Work Status:
Currently Working: Regular Duty
Light Duty
Not working due to this problem
Currently receiving or planning to receive disability? Yes
No
Current Job/Occupation: _______________________
8. How severe is your pain? (Rate on a scale from 0-10,
1. Body part we will be seeing you for (ex: left knee):
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10 is worse)______________________________________
_____________
Right
Left ___________________
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9. Does your pain keep you awake at night?
Yes
No
2. Date of injury or onset:__________________________
3. Describe where and how the problem occurred:
10. How often does the pain occur?
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________________________________________________
Constant
Intermittent
Recurring
________________________________________________
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11. How would you describe the pain?
Sharp
Dull
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4. Have you ever injured this area before?
Yes
No
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Stabbing
Throbbing
Aching
Burning
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5. Have you been treated for this condition?
Yes
No
12. Do you have any of the following:
If yes, treating physician/ER: ________________________
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Swelling
Bruising
Tingling
Weakness
Describe the treatment:_____________________________
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Redness
Numbness
________________________________________________
13. What makes your symptoms worse?
6. Have you had any diagnostic studies
(Xrays, MRI, etc.)
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Standing
Walking
Lifting
Bending
Exercise
done for this problem?
Yes
No
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Twisting
Squatting
Kneeling
Stairs
Sitting
If yes, please list:
________________________________________________
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Coughing/Sneezing
Other_______________________
Approx. Date:________________ Location performed:
14. What makes your symptoms better?
_______________________________________________
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Rest
Ice
Heat
Other_______________________
7. What medications have you taken for this problem?
15. Since my problem started, it is now:
________________________________________________
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Better
Worse
Unchanged
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Any relief from those medications?
Yes
No
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Partial
Temporary How long? __________________
NGPG 505001-03110 A (03/10/2016)