History of Present Illness
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Please select the clinic location you will be visiting.
The clinic location is not in the list
---------- Date of Birth ----------
First Name
Last Name
Month
Day
Year
Gender
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Male
Female
Your clinic location is not in the list of locations above. You will need to notify the clinic that your clinic location is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of the missing clinic location below. The clinic will be notified that the clinic location's name is missing.
Clinic Location
Email address for access to Patient Portal:
CHIEF COMPLAINT
Which area is experiencing the greatest pain / problem?
neck
ankle
hip
elbow
shoulder
knee
hand
wrist
foot
back
finger
toe
leg
PAIN
Location of pain:
left
right
both
shoulder
upper arm
elbow
lower arm
wrist
hand
finger
hip
left
right
both
groin
thigh
knee
lower leg
ankle
foot
toes
neck
collar bone
back
pelvis
other (please specify):
Are you currently experiencing pain?
Yes
No
0 = no pain 10 = most severe pain imaginable
0
1
2
3
4
5
6
7
8
9
10
Severity of pain:
Quality of pain:
aching
burning
clicking
dull
instability
locking
numbness
pins / needles
sharp
swelling
tingling
throbbing
Timing of pain (when it started):
in the last week
1-3 months
6-12 months
in the last month
3-6 months
over 1 year
Duration of pain (how long it lasts):
continuous
occasional
at night
other (please specify):
What makes your pain WORSE?
standing
laying down
bending
sitting
walking
running
kneeling
driving
weather
squatting
overhead activities
What makes your pain BETTER?
medication
standing
rest
ice
walking
sitting
massage
heat
exercise
physical therapy
elevation
laying down
TREATMENTS
Which treatment(s) have you had for your current problem?
brace / splint
Did this treatment help?
Yes
No
crutches
Did this treatment help?
Yes
No
elevation
Did this treatment help?
Yes
No
heat
Did this treatment help?
Yes
No
ice
Did this treatment help?
Yes
No
injection
Did this treatment help?
Yes
No
medication
Did this treatment help?
Yes
No
physical therapy
Did this treatment help?
Yes
No
rest
Did this treatment help?
Yes
No
stretching
Did this treatment help?
Yes
No
surgery
Did this treatment help?
Yes
No
None
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 505
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.