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| Date: _______________ Chart # _______________ Provider ____________________________________ | ||||
| Patient Name (Print) _______________________________________________________________________ | ||||
| Age: _____ Sex: M / F Dominant Hand: R / L Height: ___ / ___ Weight: _____ Did you bring X-rays? Y / N | ||||
| Who requested that you visit this office? (Check one) Doctor (Name) ___________________________________ | ||||
| Self-Referral Attorney (Name) ____________________________ Other _________________________ | ||||
| 1. | (CC*) What is the main reason for this visit? Pain Numbness Weakness Other _______________ | |||
| 2. | (HPI*) What body part is involved? ______________________________________________________ | |||
| 3. | How long ago did it start? ___ Days Wks Mths Yrs Have you had a problem like this before? Y / N | |||
| 4. | Please check the box which best describes how your problem started and describe below. | |||
| NO INJURY (Onset was) Gradual Sudden ___________________________________________ | ||||
| INJURY (From Accident or Sport NOT Auto or Work) Date ________________________________________ | ||||
| INJURY AT WORK - Date __________ From a Lift Twist Bend Pull Reach _________ | ||||
| WORK RELATED (But NO injury) - Date __________ How did your job cause this problem? | ||||
| AUTO ACCIDENT - Date __________ How was your car hit? ____________________________________ | ||||
| _______________________________________________________________________________________________ | ||||
| _______________________________________________________________________________________________ | ||||
| _______________________________________________________________________________________________ | ||||
| _______________________________________________________________________________________________ | ||||
| 5. | On a scale of 0-10 (10 is the worst) how severe is your pain? (circle) 0 1 2 3 4 5 6 7 8 9 10 (severity) | |||
| 6. | What is the quality of the pain? Sharp Dull Stabbing Throbbing Aching Burning _________ | |||
| 7. | The pain is Constant Comes & goes (Intermittent). Does your pain wake you from sleep? Y / N | |||
| Do you have Swelling Bruise Numbness Tingling Weakness Loss of control of bowel or bladder? | ||||
| Since my problem started, it is Getting better Getting worse Unchanged ________________________ | ||||
| What makes your symptoms worse? Standing Walking Lifting Exercise Twisting Bending | ||||
| Lying in bed Squatting Kneeling Stairs Sitting Coughing Sneezing | ||||
| What makes you feel better? Rest Heat Ice Elevation Other _____________________________ | ||||
| What medications have you taken or been prescribed for this problem? ____________________________________ | ||||
| _______________________________________________________________________________________________ | ||||
| Check which treatments that you have tried: Injection Brace Therapy Cane/Crutch | ||||
| Were you seen in the Emergency Room for this problem? Y / N Which ER? _______________ Date ____________ | ||||
| What tests/scans have you had for this problem X-ray MRI CAT scan Bone scan Nerve Test | ||||
| Have you already had surgery for a problem in this same area? Y / N | ||||
| Procedure #1 __________________________ Surgeon ___________________ City ____________ Date _________ | ||||
| Procedure #2 __________________________ Surgeon ___________________ City ____________ Date _________ | ||||
| Are you out of work due to this condition? Y / N When is the last date worked your regular job? _______________ | ||||
© 2004 Scott L. Smith, MD, PLLC