Yes no may we share information with referring

□ 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.