Patient History Form

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?

If "other" please explain.

Do you have associated symptoms in the:

What is the nature of these symptoms?

What side are the symptoms on?

Do you have another complaint? (explain)

At work and at home do you sit or stand more?

What is your current work status?

Do you exercise very regularly?

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

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)

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?

Have you had back or neck surgery?

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:

Indicate any other health condition you wish to note:

Have your symptoms been getting better, worse or no change recently?

Which symptom was first?

Check the activities that are affected by your pain and symptoms:

Now click on the "Submit" button below. (Remember to fill out Patient History Form-"page 2")

Patient History Form (page 1)