Patient Information
Full name
*
Date of birth
*
Phone number
*
Email address
*
Primary care provider (name and practice)
Referring provider (name and practice)
Preferred pharmacy (name and location)
Insurance Information
Insurance provider
Insurance ID / Member ID
Group number
1. Main Pain Concern
What is the main reason for your visit today?
Where is your pain located? Check all that apply
Neck
Shoulder
Arm / Elbow
Hand / Wrist
Upper Back
Lower Back
Hip
Leg / Knee
Foot / Ankle
Pelvis
Whole Body
Other
If Other, describe the location
When did this pain start?
When did this pain start?
How long ago did it start?
Was there an injury, accident, fall, or surgery related to this pain?
Yes
No
If yes, what type?
Auto
Work-related
Slip / Fall
Surgery
Other
If injury type is Other, describe
Date(s) of injury
Is your pain related to the injury?
Same
Increased
Decreased
N/A - no injury
Location of accident
Mechanism of accident
Rear-ended
Front impact
Side impact
Multi-vehicle collision
Other
N/A - not a vehicle accident
If mechanism is Other, describe
Your position in the vehicle
Driver
Front-seat passenger
Rear-seat passenger
N/A
Were you wearing a seat belt / restraint?
Yes
No
N/A
Airbag deployment
Yes
No
Unknown
Head impact
Yes
No
Unknown
Loss of consciousness
Yes
No
Unknown
Direct body impact - describe any impact to your head, neck, back, shoulder, knee, etc.
Immediate symptoms after the accident
Neck pain
Back pain
Shoulder pain
Headache
Numbness
Tingling
Weakness
Other
Other immediate symptoms
Were you evaluated in an emergency setting after the accident?
Yes
No
If yes, where were you evaluated?
ER
Hospital
Urgent care
Other
Facility name (or Other setting)
Date of evaluation (MM/DD/YYYY)
Diagnostic studies following the accident
X-ray
CT
MRI
Other
None
If Other study, name it
Initial treatment after the accident
Medications
Physical therapy
Chiropractic care
Injections
ER treatment
Other
None
If Other treatment, describe
Changes in symptoms since the accident
Persistent
Worsening
Improving
Intermittent
Please describe what happened
2. Pain Severity and Pattern
Pain RIGHT NOW (0-10)
Pain RIGHT NOW (0-10)
WORST pain this week (0-10)
WORST pain this week (0-10)
BEST pain this week (0-10)
BEST pain this week (0-10)
AVERAGE pain this week (0-10)
AVERAGE pain this week (0-10)
How often is the pain present?
Constant
Most of the day
Intermittent
Occasional
How would you describe the pain? Check all that apply
Aching
Dull
Sharp
Shooting
Burning
Throbbing
Stabbing
Tingling
Numbness
Knife-like
Other
If Other, describe the pain
What makes the pain worse? Check all that apply
Physical activity
Lifting
Bending
Twisting
Sitting
Standing
Walking
Other
Other things that make the pain worse
What makes the pain better? Check all that apply
Nothing
Lying down
Medications
Physical activity
Rest
Other
Other things that make the pain better
3. Associated Symptoms & Impact
Do you have any of the following with your pain?
Weakness
Numbness
Tingling
Falls
Loss of balance
Night sweats
Sexual dysfunction
Depression
Sleeping difficulty
Other
None of the above
Other symptoms
Which activities are affected by your pain?
Walking
Standing
Sitting
Bending
Lifting
Sleeping
Driving
Work
Exercise
Household chores
Mood / Concentration
None of the above
Other activities affected
4. Pain Location Map
FRONT of body - check every area that hurts
Head / face
Neck
Right shoulder
Left shoulder
Right arm / elbow
Left arm / elbow
Right hand / wrist
Left hand / wrist
Chest
Right upper abdomen
Left upper abdomen
Right lower abdomen
Left lower abdomen
Right hip / groin
Left hip / groin
Right thigh
Left thigh
Right knee
Left knee
Right shin / calf
Left shin / calf
Right foot / ankle
Left foot / ankle
No pain on the front of my body
BACK of body - check every area that hurts
Back of head
Neck
Right shoulder blade
Left shoulder blade
Upper back
Mid back
Lower back
Right posterior arm / elbow / hand
Left posterior arm / elbow / hand
Right buttock
Left buttock
Right posterior thigh
Left posterior thigh
Right knee (back)
Left knee (back)
Right calf
Left calf
Right heel
Left heel
No pain on the back of my body
Additional description / side / radiation
5. Previous Tests / Imaging
Check each test you have had for this pain
X-Ray
CT / CAT
MRI
EMG / Nerve Conduction Study
Bone Scan
Myelogram
Other
None - no prior testing
If Other, name the test
For each test checked, give the body area, date, facility, and result if known (type N/A if you have had none)
Upload imaging report (optional)
Upload imaging report (optional)
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Have you been told of any important abnormal finding?
Yes
No
If yes, describe the finding
6. Previous Treatments
Check all treatments you have tried for this pain
Medications
Physical Therapy - Land
Physical Therapy - Aquatic
Home Exercise
TENS
Cold Packs
Heat Therapy
Electrical Stimulation
Massage Therapy
Psychotherapy / Hypnotherapy
Acupuncture
Injections / Nerve Blocks
Surgery
Other
None - I have not tried any treatment
If Other, name the treatment
Treatment 1 - name
Treatment 1 - when / how long
Treatment 1 - relief (%)
Treatment 1 - did it help?
Yes
No
Treatment 2 - name
Treatment 2 - when / how long
Treatment 2 - relief (%)
Treatment 2 - did it help?
Yes
No
Treatment 3 - name
Treatment 3 - when / how long
Treatment 3 - relief (%)
Treatment 3 - did it help?
Yes
No
What helped overall, if anything?
7. Previous Physicians Who Treated Your Pain
Physician 1 - name
Physician 1 - specialty
Physician 1 - did they relieve your pain?
Yes
No
Physician 2 - name
Physician 2 - specialty
Physician 2 - did they relieve your pain?
Yes
No
Physician 3 - name
Physician 3 - specialty
Physician 3 - did they relieve your pain?
Yes
No
8. Emergency Room / Litigation
How often have you gone to the Emergency Room because of pain in the last year?
Is there any litigation associated with your condition?
Yes
No
Is your claim still open?
Yes
No
N/A
If yes to litigation, please describe
Attorney involved (name and firm)
9. Current & Previous Medications
CURRENT PAIN MEDICATIONS - name, dose, frequency, reason for use, whether it helps, relief %, side effects
OTHER CURRENT MEDICATIONS - all other prescription, OTC, and supplements (name, dose, frequency, reason)
PREVIOUS PAIN MEDICATIONS - name, dose if known, and reason stopped
Any medication side effects or reactions?
Do you take a blood thinner / anticoagulant?
Yes
No
If yes, which one?
Aspirin
Plavix
Coumadin
Other
None - not on a blood thinner
If Other, name the blood thinner (e.g. Eliquis, Xarelto)
Blood thinner dose (type N/A if none)
10. Allergies / Intolerances
Do you have any known allergies?
No Known Allergies
Yes
List each allergen and the reaction (type N/A if you have no known allergies)
Drug allergies
None known
Sulfa
Penicillin
Other
Other drug allergy
Food allergy and reaction
Contrast / X-Ray dye allergy and reaction
Iodine allergy and reaction
11. Past Medical History
Diabetes
No
Type I
Type II
Yes - type unknown
If diabetic, is it well controlled?
Yes
No
N/A
Check all that apply
Hypertension / High Blood Pressure
Heart Disease / CAD
Irregular Heart Beats
Angina
Stroke
Lung Disease
Asthma
COPD
HIV
Hepatitis B
Hepatitis C
Kidney Disease
Renal Failure
Cancer
Thyroid Problem
Hypothyroidism
Hyperthyroidism
Psychiatric Disease
Depression
Bipolar
Anxiety
PTSD
Arthritis
Sleep Apnea
Other
None of the above
Other medical condition(s)
If psychiatric condition is Other, describe
If cancer: location, metastasis, treatment received
Do you see a psychiatrist for your condition?
Yes
No
If yes, psychiatrist name
12. Past Surgical History
Check all surgeries you have had
Spine Surgery
Heart Surgery
Lung Surgery
Joint Replacement
Gallbladder
Tonsillectomy
Fracture Surgery
Appendectomy
Hysterectomy
Other
None - no surgeries
If spine surgery: check the region(s) and the type(s) performed (list each surgery with its level in the details box below)
Cervical
Thoracic
Lumbar
Laminectomy
Fusion
Foraminotomy
Microdiscectomy
If heart surgery
Bypass
Valve Replacement
Other
If joint replacement
Knee
Hip
Shoulder
Other
Other surgery (including other heart or joint surgery)
Surgery name(s), body area, and date(s) if known - list each spine surgery with its region and type
13. Miscellaneous Health Questions
Are you pregnant?
Yes
No
Not Applicable
Are you currently taking anticoagulation / blood-thinning medication?
Yes
No
If yes, medication and dose
14. Social History
Marital Status
Single
Married
Divorced
Separated
Widowed
Number of children
Number of persons living in household
Tobacco use
Yes
No
If yes, cigarettes / packs per day
Alcohol use
Yes
No
If yes, drinks per day or week
Recreational drug use
Yes
No
If yes, what kind and when last used
Occupation
Employment status
Employment status
If employment status is Other, describe
Hand dominance
Right
Left
Ambidextrous
15. Family History
Is any close relative suffering from a major medical problem?
Yes
No
Unsure
Father - conditions
Mother - conditions
Siblings - conditions
16. Review of Systems
GENERAL
Fever
Chills
Weight Loss
Weight Gain
Dizziness
Night Sweats
Swollen Lymph Glands
SKIN
Bruises
Itching
Rash
Hair Loss
Excessive Hair Growth
HEENT
Vision Problem
Eye Pain
Eye Discharge
Hearing Loss
Ear Pain
Ear Discharge
Mouth Soreness
Toothache
Sores on Lips/Gums
Neck Swelling
Neck Stiffness
Restricted Movement
Nose Discharge
Nose Bleeding
Throat Soreness
Hoarseness
Voice Change
Other
BREAST
Swelling
Lumps
Pain
Tenderness
LUNGS
Coughing
Shortness of Breath
Wheezing
CARDIAC
Fluttering
Skipping
Pounding
Chest Pain
GASTROINTESTINAL
Nausea
Vomiting
Diarrhea
Constipation
URINARY
Blood in Urine
Frequency of Urine
Burning While Urinating
BOWEL
Loss of Control
BLADDER
Loss of Control
Hesitancy
Frequency
NERVOUS SYSTEM
Seizures
Headaches
Weakness
Dizziness
Numbness
Tingling
Loss of Consciousness
PSYCHIATRY
Depression
Suicidal Ideas
Anxiety
Memory Loss
Insomnia
SEXUAL
Impotency
Difficulty with Erection
Loss of Interest
MUSCULOSKELETAL
Soreness
Fractures
Sprain
Swelling
Stiffness
Other symptoms (including any HEENT 'Other')
17. Patient Certification
I certify that the information provided is true and complete to the best of my knowledge.
*
I certify this information is true and complete
Patient / Guardian name (typed signature)
*
Date (MM/DD/YYYY)
*
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