Patient Medical History Form

Reason for Visit & Pain Description

Patients full name:

Last Name*

First Name*

MI

Sex*

Male

Female

Date of Birth

Please describe what brings you to the office today?

How would you describe your pain?

sharp

aching

throbbing

shooting

electrical sensation

pins and needles

burning

How long has your problems been present?

1 - 3 days

3 - 7 days

1 - 3 weeks

3 - 6 weeks

6 - 8 weeks

3 - 6 months

6 - 9 months

9 - 12 months

greater than 1 year

Onset of condition or injury:

gradual onset over time

sudden onset from activity

Course/progression of condition:

severe worsening

moderate worsening

mild worsening

steady / unchanging

mild improvement

moderate improvement

considerable/good improvement

Pain / condition aggravated by:

Have you attempted any treatments to relieve your problem?

How much improvement and relief have you achieved with previous treatments?

mild improvement

moderate worsening

considerable improvement

no improvement

worsening of condition

What is your activity level at work:

sitting

standing

walking

considerable movement/walking

retired

Reason for Visit & Pain Description

Treatment History & General Medical History

System Review - ENT, Respiratory, Cardiovascular & Gastrointestinal

System Review - Musculoskeletal, Neurological, Psychiatric & Other Systems

Surgical & Hospitalization History

Past medical history - injuries/truama

Childhood & Family History

Family History - Father

Social History, Allergies & Physical Metrics

Women