□ Yes □ No May we share information with: Referring Physician? □ Yes □ No IF PATIENT IS A MINOR OR STUDENT UNDER THE AGE OF 18 Father’s Name: Mother’s Name: Address: Address: Phone: Phone: Social Security Number: Social Security Number: Date of Birth: Date of Birth: 2
HISTORY OF PRESENT ILLNESS Where is your pain located? (i.e. wrist, ankle, low back) □ Right□ Lef Which is your dominant hand? Approximate date of the onset of the problem: How did the problem occur? Any previous problems to this area? If yes, describe: Who have you seen for this problem? (Emergency room, family physician, etc.)List past tests or treatments: (X-ray, MRI, splint, surgery, medicine, physical therapy, etc.)Intensity of pain (circle one): None 1 2 3 4 5 6 7 8 9 10 Timing of pain/problem: (When symptoms occur; example: afer exercise/activities, rest, etc.) Duration of pain/problem: (How long have you had symptoms/pain? How long does it last?) Type of pain: □ Burning □ Aching □ Stabbing □ Sharp □ Shooting □ Deep □Other Does the pain radiate? □ Yes □ No If yes, to where? What makes the pain better? What makes the pain worse? Is the pain: □ Constant □ Intermittent Is it getting: □ Better □Worse □Staying the same Any swelling: □Yes □No When do you notice it? Do you note any weakness? □Yes □No Where? Do you note any numbness, tingling? □Yes □No Where? Is it: □Constant □Intermittent What causes it? Have you ever had any problems in the past with this extremity (any type)? □Yes □No What problems? 3
PATIENT HISTORY FORM I have no know allergies (Check if no) □ Please describe the ALLERGY and the REACTION (rash, hives, breathing problems) below. Allergy Reaction Allergy Reaction Allergy Reaction I am not taking any medication at this time (Check if no) □ Please list medications below (include prescribed medications, birth control, herbals, vitamins, etc.) Please indicate the MEDICATION NAME and DOSE below.
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- Fall '18
- Allie Kotzian