Patient History Form

Patient History Form (page 1)
The following questions will provide the doctor more detailed information about the condition you wish treated, as well as some information about other conditions you may have.
Patient Name (required)*

First NameLast Name
What is your primary complaint?

neck painmid back pain (pain between the shoulders)low back painheadachestailbone painother
If "other" please explain.
Do you have associated symptoms in the:

shoulderarm, above the elbowforearm, below the elbowhandsfingershead or facerib cage or chesthipthigh, above the kneeleg, below the kneefoottoes
What is the nature of these symptoms?

paintinglingnumbnessburningstabbing
What side are the symptoms on?

rightleftboth right and left
Do you have another complaint? (explain)
At work and at home do you sit or stand more?

sitsit and stand about the same amountstand
What is your current work status?

working full or part timein between jobsdisabledhomemakerstudent
Do you exercise very regularly?

NoYes
How long have you had general problems with your back/neck? (any problems at all)

Never (This is the very first time I have ever had a problem.)Less than 3 months3 to 6 months6 to 12 monthsMore than a yearMore than 5 yearsMore than 10 yearsMore than 20 years
Have you had the same or similar back or neck problems in the past? (This includes minor problems in the same area of your spine)

NoYes
When did you have your most recent big flare up of symptoms?

MonthDayYear
If you have had repeated flare ups of this condition, how many have you had?

less than 5 flare upsless than 10 flare upsmore than 10 flare ups
Have you had back or neck surgery?

NoYes
If "yes" to the above question, indicate the type of surgery. (ie. "laminectomy of L5/S1" or "fusion of C5 through C7"
Indicate the date of the spine surgery:

MonthDayYear
Place a check beside each health condition you have or have had in the past:

diabetesfibromyalgiaheart diseasehigh blood pressurehigh cholesterolmigraines/headachesover weightosteoporosisGERD (gastro-esophageal reflux disease)depressioncancerrecent infectionscoliosis
Indicate any other health condition you wish to note:
Have your symptoms been getting better, worse or no change recently?

betterworseno change
Which symptom was first?

spine symptomarm, leg or head symptomall my symptoms happened at the same time
Check the activities that are affected by your pain and symptoms:

bendinggetting in and out of carsclimbingusing computersconcentratingcookingdressingdrivingeatingexercisinggardeninggraspinggroominghouseworkirritabilityliftinglying in bedreadingrecreationrising from lying downrising from sittingrotating neckrotating backsexual difficultyshoppingsittingsleepingsportsstair climbingstandingstresstravelingtwistingwalkingwashingworkingmy symptoms are worse in the morningmy symptoms are worse in the eveningmy symptoms are worse when I breath deeply
Now click on the "Submit" button below. (Remember to fill out Patient History Form-"page 2")
Should be Empty:

Patient History Form (page 1)