Patient Questionnaire Template - Upper Quarter And Cervical Spine Page 2
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4Name of Occupation: _____________ Out of Work Since: _______
Return to Work Date: _______
❑ Full Time
❑ Part Time
Work Status — Check the ONE that best describes your status:
❑ Light Duty
❑ Transitional Duty
❑ Out of Work ❑ Retired
❑ Not Working
❑ Homemaker
❑ Sedentary
❑ Light
❑ Medium
❑ Heavy
❑ Very Heavy
Description of your Occupation:
Is there an attorney involved? ❑ Yes ❑ No — Who? _____________
Attorney’s Office #: ________
Medical History — Check ALL that apply AND provide descriptions:
❑ Osteoarthritis ____________________________
❑ Cardiovascular Disease _____________________
❑ Diabetes Mellitus: ________________________
❑ Emotional/Psychological _____________________
❑ Type 1 ❑ Type 2
If yes:
Managed: ❑ Insulin ❑ Meds. ❑ Diet
❑ Allergies _________________________________
❑ Currently Pregnant _______________________
❑ Asthma __________________________________
❑ Cancer: ________________________________
❑ Smoking: _________________________________
If yes: Packs per day: ______
❑ Epilepsy/Seizures ________________________
Quit? __ year(s) __ month(s) __ week(s) __ day(s)
❑ Migraines/Headaches _____________________
❑ Dizziness/Fainting: Describe: _________________
If yes, is the pain: ❑ Greater on one side
❑ Trigger(s):______________________________
❑ Equal on both sides
❑ How Long Does the Dizziness Last:__________
❑ Prior Therapy: ❑ OT
❑ PT
❑ Chiropractic
❑ Surgical History____________________________
For: ___________________________________
❑ Implantable medical device(s)_______________
❑ Splint/Cast/Sling: If so, how long? ______________
❑ Pacemaker
Type: ____________________________________
❑ Defibrillator
❑ Other: _______________________________
❑ History of Falls: ❑ Yes ❑ No, If Yes, Explain:
________________________________________
Diagnostic Testing/Procedures — Check ALL that apply WITH DATES & RESULTS:
❑ CT - Date: ______________
❑ MRI - Date: ______________
❑ EMG - Date: _________________
Results: ________________
Results: _________________
Results: __________________
❑ Myelogram - Date: ________
❑ Bone Scan - Date: _________ ❑ Other __________ - Date: ______
Results:_________________
Results: _________________
Results: _____________________
❑ Steroid Injections in Muscles - Date: _____________
❑ Epidural Steroid Injections - Date: _________
Results ____________________________________
Results ______________________________
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