health questionnaire

Spouse/partner *

Emergency contact *

Phone number *

Allergies and Sensitivities

Are you allergic to, or have you had a bad reaction to, any medication or other element? *

Yes No

If YES, please complete the section below.

Medications

Please list all the current medications you are currently taking, including those you buy without a doctor’s prescription.

Medication Name, Dose, Number you take per day *

Present illness

Reason for visit *

When did this condition first begin *

List your current symptoms *

Spine Patient:

Is your pain associated with the following: (check all that apply)

What percentage of the pain is in your Neck or Back vs. Arms or Legs?

% Neck / Back *

% Arms / Legs (Total Should Equal 100%) *

Do you have pain continuously or sometimes? *

Since your pain first started, has it been getting: *

Rate your pain over the last two weeks, 0 = no pain, 10 = severe pain. *

When is your pain most painful: *

Have you lost any control of bowel or bladder function *

Describe any regular exercise *

Any chance of pregnancy? *

What recreational activities have you given up because of pain? *

Have you had any numbness or weakness?, If so where? *

Past medical history

Please indicate if you see or have been a user of any of the following substances:

Amount per day

Cigarettes *

Cigar pipe, Tobacco, etc. *

# per years

Cocaine *

Caffeine ( coffee, tea, cola ) *

Have you quit?

Marijuana *

List all past surgeries *

What is your current work status? Are you currently working ( full time, temp., disabled, etc. ) *