Patient Information
 
 
 
 
 
 
 
 
 
 
What is your height?
 
 
 

What is the reason for today’s visit?
 
 

Is your visit related to an accident / injury?
 
 
Where did the accident / injury occur?
 
 
 
 

Date of onset:
 
 

How long have you experienced the problem that has brought you to our office?
 
# of weeks
 
 
# of months
 
 
# of years
 
 

Current severity of symptom(s) on a scale of 0 – 10 (0 = least painful 10 = most painful)
 
 

Medications

Please list all medications you are currently taking.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pharmacy name, address and phone number:
 
 

Are you currently taking any diet pills or have taken them in the past?
 
 
 

Have you taken any type of blood thinners (Baby Aspirin, Coumadin, Plavix, Pradaxa, Vitamin E, etc.)?
 
 
 
 
Drug name
 
 
How long
 
 
Date stopped
 
 

Allergies

 
 
 
 
 
 
 
 
 
 
 
 
Other Allergies:
 
 
Race
 
 
 
 
 
 

Ethnicity
 
 
 

Preferred language
 
 
 
 
 
 
 
Other Languages:
 
 

Previous Treatments and Tests

Have you had any of the following treatments or tests for this problem?
 
 
 
 
 
 
 
 
Other Treatments:
 
 

Where and when did you have the test(s) or treatment(s)?
 
 

Have you had surgery related to today’s visit?
 
 
Date and type of surgery:
 
 

For your current condition, have you tried the following?
 
 
Physical Therapy
 
 
 
How Long?
 
 
 
Brace
 
 
 
How Long?
 
 
 
Cervical Traction
 
 
 
How Long?
 
 
 
Splint
 
 
 
How Long?
 
 
 
Epidural Blocks
 
 
 
How Long?
 
 
 
Bed Rest
 
 
 
How Long?
 
 

List all doctors that you currently see:
 
 

Social History

What is your occupation?
 
 

What is your marital status?
 
 
 
 
 
 
 

Please describe your cigarette smoking status.
 
 
 
 
 
 
 
How many packs per day?
 
 
 
 
 
 

Counseled to quit smoking?
 
 
 

Do you drink alcohol?
 
 
 
 
How many drinks per week?
 
 
 
 
 
 

How often do you exercise?
 
 
 
 
 
 

Medical History

Do you have any past medical history?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other Medical:
 
 
 

Family Medical History

Do you have any family medical history?
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Review of Symptoms

General

 
 
 
 
 
 
 

Eyes

 
 
 
 

Ear, Nose, and Throat

 
 
 
 
 
 

Cardiovascular

 
 
 
 
 
 

Respiratory

 
 
 
 
 

Gastrointestinal

 
 
 
 
 
 
Are you experiencing any bowel changes regarding your visit today?
 
 
 

Genitourinary

 
Are you experiencing any bladder changes regarding your visit today?
 
 
 

Musculoskeletal

 
 
 
 
 
 

Neurologic

 
 
 
 
 
 
 

Skin

 
 
 
 
 
 

Surgical History

Do you have any surgical history?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Heart Surgery
 
 
 
 
Spinal Fusion
 
 
 
Other Surgeries:
 
 

Do you have any implants?
 
 
 
 
 
 
 
 
 
 
Other Implants:
 
 
 

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 443
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.