Patient Information (Full Legal Name)
 
 
 
 
 
 
 
 
 
 
Why are you coming to Buffalo Spine and Sports?                  
 
 

Chief Complaint

What is your main complaint:  
 
Location of your symptoms:
 
Shoulder  
 
 
Arm (upper)  
 
 
Forearm  
 
 
Elbow  
 
 
Wrist  
 
 
Hand / Finger(s)  
 
 
Buttock  
 
 
Groin  
 
 
Hip  
 
 
Thigh  
 
 
Knee  
 
 
Lower Leg  
 
 
Ankle  
 
 
Foot / Toe(s)  
 
 
Head / Headache  
 
 
Face / Jaw  
 
 
Neck (Cervical Spine)  
 
 
Upper Back (Thoracic Spine)  
 
 
Lower Back (Lumbar Spine)  
 
 
Abdomen / Pelvis  
 
 
Breast / Chest Wall  
 
 
How would you rate your overall pain level now? (0 being no pain to 10 being most severe)
 
 
 
 
 
 
 
 
 
 
 
 
Description of symptoms:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is your pain:  
 
Recently your symptoms are:  
 
 
 
 

Duration / Onset

What date did your symptoms begin?      
 
When did symptoms begin?  
 
 
How did your pain / symptoms happen?  
 
If this is due to an injury, where did it happen?
 
 
 
 
 
 
 
 
 
 
Have you or will you file a workers' compensation claim, no-fault (motor vehicle) claim, or liability claim?
 
 
 
 
 
Which one?
 
 
 
 
 
 

Work Status

Are you currently working?
 
 
 
 
 
 
 
 
 
 
Last time you regularly worked?
 
     
 
 

Symptoms

Have you ever had symptoms, injury, or pain to this area previously?
 
 
 
What percent of recovery did you have?
 
 
 
 
 
 
 
 
 
 
 
 

(Worsens Symptoms)

 
What activities WORSEN your symptoms?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

(Relieves Symptons)

 
What activities RELIEVE your symptoms?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pervious Imaging Studies/Injections

 
Have you had any of the following studies for this condition?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Have you had any injections for your pain?
 
 
What type:
 
 
 
 
 
 
 
 

Social History

 
What is your dominant hand?  
 
What is your occupation?
 
 
What is your marital status?
 
 
 
 
 
 
Who are you living with?
 
 
 
 
 
 
 
 
 
How many children do you have?
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the highest level of education you completed?
 
 
 
 
Do you Smoke?
 
 
 
How many packs per day:
 
 
 
 
 
 
Did you smoke in the past?
 
 
Do you drink alcohol?  
 
 
Drinks per week:
 
 
 
 
 
Do you exercise?
 
 
 
 

Past Medical History

 
Are you or could you be pregnant?  
 
Do you have any past medical history?  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cancer:  
 
 
 

Family Medical History

 
Do you have any family medical history?
 
 
 
 
 
Please indicate if your parents, grandparents, or siblings have had any of the following:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Past Surgical History

Do you have any surgical history?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Spine Surgeries:
 
 
 
 
 
 
 
 
 
Did you improve after surgery?
 
 
Other Surgeries:
 
Arthroscopic  
 
 
Total knee replacement  
 
 
Total hip replacement  
 
 
Hip fracture and surgery  
 
 
Arthroscopic shoulder  
 
 
Total shoulder replacement  
 
 
Rotator cuff repair  
 
 
Carpal tunnel  
 
 
Hand  
 
 
Ulnar nerve  
 
 
Orthopedic (bone)  
 
 
Foot / ankle / toes  
 
 
Abdominal / Pelvic  
Cesarean section  
 
 
Hysterectomy  
 
Mastectomy  
 
 
Ovary removal  
 
 
 
 

Review of Systems

 
General
 
 
 
 
 
 
 
 
 
 
Musculoskeletal
 
 
 
 
 
 
 
 
 
 
Neurologic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Genitourinary
 
 
 
 
 
Eyes
 
 
 
 
 
Ears / Nose / Throat
 
 
 
 
Cardiovascular
 
 
 
 
 
 
 
 
 
 
Respiratory
 
 
 
 
 
Gastrointestinal
 
 
 
 
 
 
 
Skin
 
 
 
 
Psychiatric
 
 
 
 
 
Endocrine
 
 
 
 
 
 
 
Heme (Blood) / Lymphatic
 
 
 
Allergic / Immunologic
 
 
 
 

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 1001
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