New Patient Medical History Page 6
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10Name:
Date:
Pain interferes with (check all that apply):
Below, indicate past treatments for pain:
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Appetite
Sleep
Sex
Type
Date
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Self-care
Hobbies
Job performance
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Nerve Blocks
Social Life
Exercise
Travelling
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Lifting
Shopping
House chores
Steroid Injections
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Driving
Cooking
Physical Therapy
What makes pain better?
Psychotherapy
Acupuncture
Surgery
What makes pain worse?
Chiropractic
Failed Meds
How far can you walk? Do you require assistance?
Other
Have you had any of the following imaging studies?
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Xray
CT Scan
MRI
Bone Scan
EMG
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Other
If yes, please list dates of scans:
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Females: LMP:
Please notify MD/NP/RN/PA, if you are pregnant.
Yes
No
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Cancer:
Yes
No
If yes, type:
Chemo:
Yes
No
Radiation:
Yes
No
If this form was completed by someone other than the patient, please list name, relation to the patient and
the reason that the patient was unable to complete the form:
Form completely by:
Date
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