PATIENT HISTORY 1 2 3 4 Family Doctor:Referring Doctor:Why are you here?Rate your pain on a 0-10 scale (0 as no pain and 10 as the most severe).NowNow012345678910Lowest(least) pain score:Lowest(least) pain score012345678910Highest(most severe) pain score:Highest(most severe) pain score012345678910What started your pain?Date: MM DD YYYY Related to:Work InjuryAccidentUnknownHow would you describe your pain? Sharp Stabbing Electrical Shooting Tingling Pressure Constant Intermittent What makes the pain worse? Lying Sitting Standing Other What makes the pain better? Rest Position Change Medication Heat Ice Lying Sitting Other Has the pain affected your sleep?YesNoCheck all the areas of your pain? Abdomen Back Head Knee Neck Pelvic Shoulder Wrist & Hand Medical Problems: Diabetes High Blood Pressure Cancer Heart Attack Stroke Other Past Surgeries(with dates, if possible): Family History:Mother: Diabetes High Blood Pressure Cancer Heart Disease Other Father: Diabetes High Blood Pressure Cancer Heart Disease Other Siblings: Diabetes High Blood Pressure Cancer Heart Disease Other Social History:Alcohol:YesNoAmount:Tobacco:YesNoHow Much?For how long?Drug Abuse:YesNoWhat Type:Status:MarriedSingleOccupation:Children: Review of Systems: N checked is Normal, Abnormal is checked with comment.Constitutional:NormalAbnormalSymptoms(checked if present): Fever Weight loss Night sweats Fatigue Loss of Appetite Symptoms(checked if present): Fever, Weight loss, Night sweats, Fatigue, Loss of Appetite.Comments:Eyes:NormalAbnormalSymptoms(checked if present): Blurring Pain Itching Redness Symptoms(checked if present): Blurring, Pain, Itching, RednessComments:Ear, nose, throat:NormalAbnormalSymptoms(checked if present): Hearing loss Ringing in the ears Nose bleeds Runny nose Facial pain Sore throat Hoarseness Symptoms(checked if present): Hearing loss, Ringing in the ears, Nose bleeds, Runny nose, Facial pain, Sore throat, HoarsenessComments:Cardiovascular (heart):NormalAbnormalSymptoms(checked if present): Skipping heartbeats Racing heart Chest pain Symptoms(checked if present): Skipping heartbeats, Racing heart, Chest painComments:Respiratory (lungs):NormalAbnormalSymptoms(checked if present): Shortness of breath Cough Wheezing Coughing blood Symptoms(checked if present): Shortness of breath, Cough, Wheezing, Coughing bloodComments:Gastrointestinal (stomach problems):NormalAbnormalSymptoms(checked if present): Indigestion Trouble swallowing Nausea Vomiting Passing blood Constipation Diarrhea Ulcers Symptoms(checked if present): Indigestion, Trouble swallowing, Nausea, Vomiting, Passing blood, Constipation, Diarrhea, UlcersComments:Urologic (kidney or bladder problems):NormalAbnormalSymptoms(checked if present): Wake up at night to go to the bathroom Incontinence Pain when you pee Discharge Symptoms(checked if present): Wake up at night to go to the bathroom, Incontinence, Pain when you pee, DischargeComments:Male reproduction:NormalAbnormalSymptoms(checked if present): Discharge Testicular pain/mass Impotence Symptoms(checked if present): Discharge, Testicular pain/mass, ImpotenceComments:Female reproduction:NormalAbnormalSymptoms(checked if present): Abnormal periods Discharge Ovary pain Symptoms(checked if present): Abnormal periods, Discharge, Ovary painComments:Muscle or joint problems:NormalAbnormalSymptoms(checked if present): Muscle pain Joint pain Joint swelling or deformity Symptoms(checked if present): Muscle pain, Joint pain, Joint swelling or deformityComments:Skin:NormalAbnormalSymptoms(checked if present): Rash Nail changes Mass Itching Scars Symptoms(checked if present): Rash, Nail changes, Mass, Itching, ScarsComments:Neurologic (nerve problems):NormalAbnormalSymptoms(checked if present): Weakness Numbness Headache Confusion Passing out Tremor Shaking Symptoms(checked if present): Weakness, Numbness, Headache, Confusion, Passing out, Tremor, ShakingComments:Psychiatric:NormalAbnormalSymptoms(checked if present): Depression Agitation Anxiety Symptoms(checked if present): Depression, Agitation, AnxietyComments:Endocrine (diabetes or thyroid problems):NormalAbnormalSymptoms(checked if present): Go to the bathroom all the time Cold/heat intolerance Tired all the time Symptoms(checked if present): Go to the bathroom all the time, Cold/heat intolerance, Tired all the timeComments:Blood problems:NormalAbnormalSymptoms(checked if present): Swollen glands Bruising easily Prolonged bleeding Symptoms(checked if present): Swollen glands, Bruising easily, Prolonged bleedingComments:Additional Comments: Current (Medications) that your are taking with dosage and frequency:Current (Over the counter medicines) you are taking:
