Patient Questionaire

Patient Name: _____________________________________ Date: _________________

Please list other doctors or therapists you have seen for this condition:

Name When were you treated? Type of treatment/therapies?

How did the injury occur?

Did you require hospitalization?

Have you had a recent major surgery or illness? Yes or No (circle one)

If yes, please describe:

Have you lost any days from work? Yes or No (circle one)

If yes, please describe:

Are you taking prescription, over-the-counter, or birth control medication? Yes/No

List medications:

Do you smoke? Yes/no (circle one) If yes, _________packs/day for ________Years.

Circle the following conditions that you or your blood relatives have had:

Back/neck problems Cancer Heart Attack

Stroke Arthritis Diabetes

High blood pressure Osteoporosis Drug/alcohol abuse

Are you pregnant? Yes or No (circle one)

Check symptoms you have noticed since the injury/accident/pain syndrome:

_____Headache _____Numbness in Fingers _____Cold Sweats

_____Neck Pain _____Numbness in Toes _____Pins/Needles in Legs

_____Neck stiffness _____Depression _____Hands Cold

_____Constipation _____Pins/Needles in Arms _____Ears Ring/Buzz

_____Back Pain _____Loss of Memory _____Feet Cold

_____Nervousness _____Head seems too heavy _____Stomach Upset

_____Tension _____Loss of Balance _____Dizziness

_____Fainting _____Diarrhea _____Sleeping Problems

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