Download 1 Patient Information Profile Please fill in bubbles completely

Patient Information Profile
Please fill in bubbles completely (example:
●Yes
O No)
Patient Name __________________________________________________ Age ________ Date _____________
Payment Source: (please choose one)
 Cash
 Credit Card
 Check
 Worker’s Comp
Who referred you to us?
 MD  Chiropractor  Friend  Patient  Attorney
 Internet: __________________________________
________________________________________
 Other: ____________________________________
Reason for your visit today: _____________________________________________________________________
Date of injury: ____________ Describe your injury: __________________________________________________
__________________________________________________
Were you in an accident?  Yes  No (If yes, please choose)  Work  Auto  Other  Pending Litigation
Complaints (pain location, intensity, radiation): _______________________________________________________
_______________________________________________________
List your current medications & doses: ____________________________________________________________
____________________________________________________________
List any medical conditions: _____________________________________________________________________
_____________________________________________________________________
List allergies to medications: ____________________________________________________________________
List any previous surgeries & dates: ______________________________________________________________
Other professionals seen for this injury: MD:
 Yes  No
Chiropractor:
 Yes  No
Surgeon:
 Yes  No
Physical Therapist:
 Yes  No
List any previous history of back pain/neck pain: _____________________________________________________
Have you had any tests for your current condition? (Mark all that apply. If Yes, give Date (MM/YY) and Results)
X-rays:
 Yes
 No
Date: _______ Results: _______________________________
MRI:
 Yes
 No
Date: _______ Results: _______________________________
CT scan:
 Yes
 No
Date: _______ Results: _______________________________
CT Myelogram:
 Yes
 No
Date: _______ Results: _______________________________
EMG:
 Yes
 No
Date: _______ Results: _______________________________
What treatment have you had for your current condition? (Mark all that apply. If Yes, give Date (MM/YY) and Results)
Therapy:
 Yes
 No
Date: _______ Results: _______________________________
Chiropractic:
 Yes
 No
Date: _______ Results: _______________________________
Tens Unit:
 Yes
 No
Date: _______ Results: _______________________________
Injections:
 Yes
 No
Date: _______ Results: _______________________________
Nerve Blocks / Epidural Steroids:
 Yes
 No
Date: _______ Results: _______________________________
Pain Clinic:
 Yes
 No
Date: _______ Results: _______________________________
Massage Therapy:
 Yes
 No
Date: _______ Results: _______________________________
Surgery:
 Yes
 No
Date: _______ Results: _______________________________
1
Patient Information Profile
Please fill in bubbles completely (example ⚫ Yes O No)
Hobbies:___________________________________
Attorney:__________________________________
Social History
What is your marital status?
Do you have children?
Employment:
Do you smoke?
Do you drink alcohol?
Do you have a disability?
Do you have a drug history?
Married
Yes
Full time
Yes
Yes
Yes
Yes
Family History
Father
Mother
Siblings
Children
Deceased
Deceased
Deceased
Deceased
Alive
Alive
Alive
Alive
Are you having any of these symptoms:
Fevers?
Yes
Weakness?
Yes
Recent weight loss?
Yes
Night sweats?
Yes
Weight gain?
Yes
Feeling very tired?
Yes
Difficulty falling asleep?
Yes
Difficulty staying asleep?
Yes
Joint swelling?
Yes
Joint pain?
Yes
Joint stiffness?
Yes
Pain in your legs?
Yes
Pain in your arms?
Yes
Neck pain?
Yes
General “all over” muscle pain?
Yes
Low back pain?
Yes
Mid back pain?
Yes
Difficulty walking?
Yes
Leg swelling?
Yes
Headaches?
Yes
Dizziness?
Yes
Nose bleeds?
Yes
Ringing in your ears?
Yes
Chest pain?
Yes
Shortness of breath?
Yes
Palpitations?
Yes
Irregular heart beat?
Yes
High blood pressure?
Yes
Fainting?
Yes
Cough?
Yes
Coughing blood?
Yes
Respiratory infections?
Yes
Tuberculosis?
Yes
History of bronchitis or pneumonia?
Yes
Single
No
Part time
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Widowed
Divorced
Disability
Retired
Unemployed
Quit
Socially
Describe:_________________________
Unknown
Unknown
Unknown
Unknown
Pertinent Family History
___________________
___________________
___________________
___________________
Wheezing?
Yes
Poor appetite?
Yes
Nausea?
Yes
Heartburn?
Yes
Loss of bowel control?
Yes
Constipation?
Yes
Diarrhea?
Yes
Difficulty urinating?
Yes
Blood in your urine?
Yes
Urinary urgency?
Yes
Frequent urination?
Yes
Loss of bladder control?
Yes
Up at night to urinate?
Yes
Anxiety?
Yes
Depression?
Yes
A high level of stress?
Yes
Nervousness?
Yes
Emotional problems?
Yes
Lack of concentration?
Yes
Convulsions?
Yes
Tremors?
Yes
Paralysis?
Yes
Lack of coordination?
Yes
Disorientation?
Yes
Blurring of vision?
Yes
Numbness & tingling in extremities?
Yes
Anemia?
Yes
Easy bruising?
Yes
Bleeding tendency?
Yes
Rash?
Yes
Hives?
Yes
Reactions to drugs?
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
During your visit with your physician today what two questions would you like answered?
1.__________________________________________________________________________
2.__________________________________________________________________________
2
Patient Information Profile
- PAIN DIAGRAM -
Date: __________
Patient Name:
1. Please mark the body diagrams where you are experiencing pain.
2. For each location marked, please indicate in the table below, the Type of Pain and the Pain Intensity.
Types of Pain include:
- Aching
- Burning
- Cramps
- Dull
- Numbness
-
Sharp
Shooting
Stabbing
Stiffness
Swelling
-
Throbbing
Tingling
Other
Pain Intensity: Use a scale from 0 (no pain) to 10 (severe pain).
Pain Location
Print Form
Clear Form
Type of Pain
Save Form
Pain Intensity
(0 – 10)
Submit Form