Patient Update Form Page 2
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1
2NAME/ADDRESS OF CLINIC/PROVIDER
PATIENT UPDATE FORM
2
NAME OF PATIENT_____________________________________
DOB_______________________
1.
What is your major symptom? _____________________________________________________
2.
If this is a recurrence, when was the first time you noticed this problem?____________________
How did it originally occur?________________________________________________________
Has it become worse recently? Yes ___ No ___ Same ___ Better ___ Gradually Worse _____
If yes, when and how? ____________________________________________________________
3.
How frequent is the condition? Constant _____ Daily ____ Intermittent ____ Night Only ___
How long does it last? All Day _________ Few Hours ___________ Minutes _______________
4.
Are there any other conditions or symptoms that may be related to your major symptom?
Yes _____ No _____. If yes, describe _____________________________________________
Are there other unrelated health problems? Yes _____ No _____. If yes, describe ___________
5.
Describe the pain: Sharp _____ Dull_____
Numbness _____ Tingling _____ Aching _____
Burning _____ Stabbing _____ Other _______________________________________________
6.
Is there anything you can do to relieve the problem? Yes ___ No ___. If yes, describe _______
____________________. If no, what have you tried to do that has not helped? ______________
______________________________________________________________________________
7.
What makes the problem worse? Standing ____ Sitting ______ Lying ______ Bending ______
Lifting _____ Twisting _____ Other ________________________________________________
8.
Have you had any broken bones? Yes ____ No ____. If yes, please list and give dates _______
______________________________________________________________________________
9.
List any major accidents you have had other than those that might be mentioned above: _______
______________________________________________________________________________
10.
To your knowledge, have you had any diseases, major illnesses, or injuries not indicated on this
form either in the past or the present?
Yes ____ No ____. If yes, please explain __________
______________________________________________________________________________
11.
WOMEN ONLY: Are you pregnant or is there any possibility you may be pregnant?
Yes _____
No _____ Uncertain _____
12.
Remarks: ______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
NO
EXTREME
SYMPTOMS
SYMPTOMS
Please place an “X” on the line above to indicate your level of problem.
Patient Signature ___________________________________________ Date _____________
Doctor’s Signature ___________________________________________ Date _____________
Reviewed by __________________________________________
Patient Update Form
Signature of Reviewer ___________________________________
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Parent category: Medical