Please choose all current and past medical conditions □ No medical condition(s) □Sleep Apnea □ Rheumatoid arthritis □ High blood pressure □ Lupus □ Bleeding disorder(s) □ Heart attack □ Parkinson’s Disease □ Anemia □ Abnormal heart rhythm □ Diabetes – Type □ Blood clots □ Lung disease/COPD □ Thyroid – Type: Hyper/Hypo □ Schizophrenia □ Tuberculosis □ Stomach ulcers □ Anxiety □ Asthma □ IBS □ Depression □ Bronchitis □ Stroke □ HIV □ Emphysema □ Seizures □ Alcoholism □ Disease □ Cancer – Type □ Anorexia/bulimia □ Hepatitis – Type □ Kidney failure □ Heart murmur □ Irregular heartbeat □ Osteoporosis □ Cheat pain * Are you under the care of another physician for ANY OTHER medical condition? □ Yes □ No If yes, please provide name and number and reason for care Surgical History Please choose all surgeries you have had: □ None □ Spine – Neck: Level(s) Date: □ Hernia/ □ Colon/ □ Rectum □ Spine – Back: Level(s) Date: □ Hysterectomy/ □ C-section □ Brain □ Carpel Tunnel – Left/Right □ Shoulder(s) – Left/Right □ Heart □ Hip(s) – Left/Right □ Knee(s) – Left/Right □ Angioplasty/ □ Stent □ Eye(s) – Left/Right □ Throat/ □ Tonsils □ Lung □ Other: □ Gallbladder/ □ Stomach □ Appendix/ □ Intestine Medication History Please list ALL medications including the dose. Please include over the counter medications and vitamin supplements. □ None
Allergies: □ No known drug allergies Latex Allergy: □ Yes □ No Complications with anesthesia □ Yes □ No Medication Name and Reaction History Are you claustrophobic? □ Yes □ No Have you ever worked with metal (welded)? □ Yes □ No Do you have metal in your body? □ Yes □ No Are you/could you be pregnant? □ Yes □ No Do you have a: □ Pacemaker □ Defibrillator □ Replacement Heart Valve □ Vena Cava Umbrella □ Implanted Pump □ Aneurysm Clip □ Neurostimulator □ Metal Plate □ Other Social History I live: □ Alone □ With: I live in a: □ House □ Apartment □ Assisted living □ Nursing home Are you a cigarette smoker? □ Yes, current for year(s) □ Never □ Former, quit: If you answered yes, how much did you smoke? □ Less than ½ pack □ ½ pack □ ¾ pack □ 1 pack □ More (How much? ) Do you drink alcoholic beverages? (Check one) □ None □ 0-3/month □ 1-2/week □ 1-2/day □ 3-5/day □ More than 5/day Have you ever had a problem with dependence? □ Yes □ No If yes, what was the dependence and for how long? Are their law suits pending or contemplated related to this condition? □ Yes □ No If yes, please provide the attorney’s name and contact number: Please write any additional information that you feel is important for us to know.
Family Medical History Mother Father Brother Sister High Blood Pressure Disease Diabetes Cancer (Type) Stroke Headaches/Migraines Arthritis Neuropathy Seizures Parkinson’s Disease Alzheimer’s/Dementia Multiple Sclerosis Please list other significant medical family history: Patient Name (Print) Date Back Only Patient Name Date: Reason for Today’s Visit: Symptoms: □ Back pain □ Leg pain □ Neck pain □ Arm pain □ Numbness □ Weakness □ Scoliosis □ Other: How long have you had your symptoms?
What caused your symptoms? □ Unknown □ Injury □ Other: What % of your symptoms are in the BACK and LEG? (please check one box) □ Back 0%, Leg 100% □ Back 10%, Leg 90% □ Back 25%, Leg 75% □ Back 50%, Leg 50% □ Back 75%, Leg 25% □ Back 90%, Leg 10% □ Back 100%, Leg 0% What % of your symptoms are in each LEG? (please check one box) □ No LEG symptoms □ 0%, Left 100% □ Right 10%, Leg 90% □ Right 25%, Left 75% □ Right 50%, Left 50% □ Right 75%, Left 25% □ Right 90%, Left 10% □ Right 100%, Left 0% Where in your LEG do you have PAIN or TINGLING? Right Left □ None □ None □ Buttock □ Buttock □ back □ Thigh, back □ Thigh, front □ Thigh, front □ Calf □ Calf □ Foot □ Foot in your LEG do you have NUMBNESS? Right Left □ None □ None □ Buttock □ Buttock □ Thigh □ Thigh □ □ Ankle □ Calf □ Calf □ Foot/toes □ Foot/toes Where in your LEG do you have WEAKNESS? Right Left □ None □ None □ Buttock □ Buttock □ Thigh □ Thigh □ □ Ankle □ Calf □ Calf □ Foot □ Foot Neck Only Patient Name (print): Date: Reason for Today’s Visit: Symptoms: □ Back pain □ Leg pain □ Neck pain □ Arm pain □ Numbness □ Weakness □ Scoliosis □