New Patient Medical History Page 5
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10New Patient Medical History
BRAIN AND SPINE CENTER NEW PATIENT QUESTIONNAIRE
Form
On the drawings below, shade the location of
On the diagram below, write X to indicate the severity of
pain. Indicate the worst area with an X.
pain you are having right now. Write L to indicate least pain.
Write W, to indicate worst pain.
D
i
d
a
n
□
□
YES
NO If yes,
accident or other event precipitate your pain?
please describe:
□
□
Were you injured at work?
YES
NO
□
□
Are you filing for Worker’s Comp?
YES
NO
□
□
Are you currently involved in litigation?
YES
NO
When did the pain start?
Frequency of pain:
Duration of pain:
times a day
seconds
times a week
minutes
On a scale from 0 to 10, please circle your level of pain
times a month
hours
or discomfort, with 0 being none and 10 being
unbearable for the following areas:
Do you experience…
Neck Pain
0 1 2 3 4 5 6 7 8 9 10
□
□
□
Weakness
Numbness
Tingling
Left Shoulder Pain
0 1 2 3 4 5 6 7 8 9 10
When is the pain worst?
Right Shoulder Pain
0 1 2 3 4 5 6 7 8 9 10
□
□
□
□
Morning
Afternoon
Evening
Night
Left Arm Pain
0 1 2 3 4 5 6 7 8 9 10
□
Changing positions
Right Arm Pain
0 1 2 3 4 5 6 7 8 9 10
Back Pain
0 1 2 3 4 5 6 7 8 9 10
Describe pain:
□
□
□
Burning
Sharp
Shooting
Left Hip/Buttock Pain
0 1 2 3 4 5 6 7 8 9 10
□
□
□
Dull
Numbness
Electrical
Right Hip/Buttock Pain 0 1 2 3 4 5 6 7 8 9 10
□
□
□
Throbbing
Aching
Cramps
□
□
Left Leg Pain
0 1 2 3 4 5 6 7 8 9 10
Gripping
Pins/Needles
Right Leg Pain
0 1 2 3 4 5 6 7 8 9 10
5
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0 votes
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