| Name |
|
Age |
|
|
|
| Birthday |
|
Address |
|
| Sex |
Male Female |
|
|
| City |
|
Province |
|
|
|
| Postal Code |
|
Home Phone |
|
|
|
| Work Phone |
|
Cell Phone |
|
|
|
| Best Place To Reach You |
Home WorkCell |
May we leave a voice mail message for you? |
Yes No |
|
|
| Employer |
|
Occupation |
|
|
|
| Marital Status |
Single Married Divorced Widowed |
|
|
| Spouses Name |
|
SIN# |
|
|
|
|
|
|
|
| How
Did You Hear About Physical Medicine Center, Inc? |
|
How Serious Do You Think Your Problem Is?- (Scale 1-5) |
|
|
|
| What Is Your Main Problem/Symptom Prompting Your Request For A Consultation With The Doctor? |
Back Neck Other |
|
|
|
|
|
|
| 1. In spite of the fact that you are not a back specialist, you are in fact the person who knows more about your back than anyone else. In your own words and in your own opinion what do you think the real problem is? |
|
|
|
| 2. What are you hoping happens today as a result of your consultation with the Doctor? |
|
|
|
| 3. Since your back pain became this severe what three things has it caused you to miss the most? |
|
|
|
| 4. How long have you been like this? |
|
|
|
| 5. How has your life changed since your back and/or neck became a problem? |
|
|
|
| 6. What activities are you limited in? |
|
|
|
| 7. What kinds of treatments have you received?
|
|
|
|
|
| 8. When did you receive these treatments and for how long? |
|
|
|
| 9. Did any of these treatments work? If so which one(s)? For how long? |
|
|
|
| 10. Is there anything you can do that makes it feel better? |
|
|
|
| 11. What activities/movements are guaranteed to make it worse? |
|
|
|
| 12. Please describe the quality of the pain. (Sharp, Dull, achy, toothache, shooting, stabbing, numb, tingling, etc.) |
|
|
|
| 13. It is worse in the morning or is it worse as the day progresses? |
|
|
|
| 14. If you cannot find a solution to this problem what do you think will happen to you? |
|
|
|
| 15. What are you hoping the Doctor tells you today? |
|
|
|
| 16. Describe what you hope or think he might be able to do for you. |
|
|
|
| 17. Describe what will be different in your life if you can get better. |
|
|
|
| 18. When is the VERY FIRST time you recall having this problem? |
|
|
|
| In Reference To Your MAIN PROBLEM How Often Are You Aware of This Problem? |
Occasionally (25% of the time)
Intermittently (50% of the time)
Frequently (75% of the time)
Constant (90-100% of the time) |
|
|
| Due To Your Main Problem...
|
|
|
|
|
| On a Scale of 0-10 (10 being unbearable, 0 being No pain or Discomfort) Please rate the following.
|
| The HIGHEST your pain gets WITHOUT medication |
|
| The LOWEST your pain gets WITHOUT medication |
|
| The HIGHEST your pain gets WITH medication |
|
| The LOWEST your pain gets WITH medication |
|
| List ANY surgeries that you have had and the corresponding dates. |
|
|
|
|
|
Have you had ANY of the following in the last 12 months or currently. (Mark C for Current. X for in last 12 mos.)
|
|
|