Patient Health History

Patient Health History Name: __________________________________ Date: DOB: _______________________________________ PCP: Age: _____________________...
Author: Barbra Baker
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Patient Health History Name: __________________________________

Date:

DOB: _______________________________________

PCP:

Age: _______________________________________

Referring:

(Office use) Dx:

Height:

B/P

HR

Weight:

T Pain Diagram and Description

BMI

Please mark the areas of your body where you feel your typical pain. Include all affected areas. Use the appropriate symbols indicated below: Ache X X X

Stabbing / / /

Pins and Needles v v v

Burns 0 0 0

Numbness = = =

Rev Date/Time/Initial _____/_____/_______ Rev Date/Time/Initial _____/_____/_______ Rev Date/Time/Initial _____/_____/_______ Rev Date/Time/Initial _____/_____/_______ Rev Date/Time/Initial _____/_____/_______ Rev Date/Time/Initial _____/_____/_______ People assisting with paperwork: Interpreter’s name

Interpreter’s Signature and/or ID #

Date and Time

Office Staff name

Office Staff Signature

Date and Time

Patient name

DOB Top Left/HH

Rev 05-05-2011

Form 10501

Page 1 of 6

Patient Health History – page 2

Pain Assessment Approximate date when your pain began? ______________________ Was this a work related injury:  No  Yes Have you had pain prior to this episode?

 No  Yes

If yes, please explain: _____________________________________

________________________________________________________________________________________________________ Please briefly describe the onset of your pain:___________________________________________________________________ ________________________________________________________________________________________________________ Please indicate the intensity of your pain. Circle the number that applies.

Your Pain is:

 Constant

 Comes/Goes

 Other________________________________________

(Please Circle the Number that describes your Level of Interference) (Answer A only if employed or medical leave not if retired or unemployed) A.

Work Activities

No Interference

0

1

2

3

4

5

6

7

8

9

10

Extreme Interference

B.

Daily Living

No Interference

0

1

2

3

4

5

6

7

8

9

10

Extreme Interference

How do these activities affect your pain? (Please check all that apply)

No Change

Relieves Pain

Increases Pain

No Change

Sitting

Lifting

Walking

Straining

Standing

Sneezing

Lying Down

Coughing

Bending Forward

NightTime/Sleep Other

Relieves Pain

Increases Pain

Bending Backwards On a scale of 0-10 (0 = no pain; 10 = worst pain imaginable), what is your goal after treatment? _______________________ Please list two activities that you would like to be able to perform but currently cannot (i.e., walk dog, yard work, play with kids/grandkids, etc.) 1. __________________________________________________ 2. __________________________________________________ Previous Treatment Please check the box for each test/treatment you have had for the CURRENT PAIN CONDITION, include when/where:

 Steroid Injections or Blocks  Physical Therapy  Chiropractic Intervention  Acupuncture  TENS Unit  Psychiatric/Psychological  Surgery/Surgeons Please list medications you have tried:

      

 Anti-Inflammatory

 Muscle Relaxants

 Pain Medications

 Prescription

 Over-the-counter

 Natural remedies

X-Ray MRI CT EMG Bone Scan Pain Specialist Other

Patient name

DOB Top Left/HH

Rev 05-05-2011

Form 10501

Page 2 of 6

Patient Health History – page 3

Past Medical History Please list current or previous medical conditions and treating physician. (Examples: High Blood Pressure, heart attack, stroke, diabetes, cancer, thyroid problems, depression, arthritis, blood clots, etc) 1. 6. 2. 3.

7. 8.

4. 5.

9. 10. Surgical History (All)

Date (M/Y)

Procedure

Surgeon

Date (M/Y)

Procedure

Surgeon

Current Medications (include all over the counter medications and herbal remedies)

Medication

Dose

# per day

Physician

Medication

Dose

# per day

Allergies Allergy (please list)

Reaction

Are you allergic to any of the following:  X-ray Contrast  Latex/Rubber  Band-aids/Tape  Betadine (lodine soap)  Eggs  Soy

Patient name

DOB Top Left/HH

Rev 05-05-2011

Form 10501

Page 3 of 6

Physician

Patient Health History – page 4

Social History Family History: Please fill in the information about your family. Disease Relationship to You Cancer Chemical Dependency Diabetes Headache Heart Disease Stroke High Blood Pressure Kidney Disease Other Marriage and Family

 Single  Widowed  Separated  Married  Divorced  Name of Spouse/Significant Other_________________  Children (how many):______Ages:________________

 Significant Other

Living Arrangements

 Alone  Spouse/Significant Other  Assisted Living  Unable to take care of yourself If unable to care for self, name of care provider __________________________________________ Social Systems

What activities are you involved in? _______________________________________________________________  No  Yes Do you have a history of Pre-adolescent Sexual Abuse? Education

Please list how many years of formal education you have received (including community college & college): _____________________________________________________________________________________________ Preferred Method of Learning

 Demonstration  Written Words  Video  Other:____________________________________ Please list any barriers to learning:______________________________________________________ Occupation: (If not currently working, please list your previous occupation) __________________________ How labor intensive is your job? Sedentary (No lifting)  No  Yes Heavy (Lift greater than 75 lbs)  No  Yes Moderate (Lift greater than 50 lbs)  No Very Heavy (Lift greater than 100 lbs)  No  Yes

 Yes

Drugs/Alcohol

Do you drink caffeine?  No  Yes Do you smoke or use tobacco in any form?  No  Yes How many packs a day:_______ Cans a week:______ # Years: _____ If not, did you ever smoke or use tobacco?  No  Yes Do you drink alcohol?  No  Yes Do you have a history of alcoholism?  No Does anyone in your family have a history of substance abuse?  No  Yes If yes who: _________________________________________________________ Do you have a history of street drug or prescription drug abuse?  No  Yes Is there any substance abuse in your household?  No  Yes If yes who: _________________________________________________________ Using or used this past year any "street" drugs? Cocaine Marijuana Crank Amphetamines Heroin Shrooms Others:________________

 Yes

Spiritual/Emotional

1. Have you had any significant life changes in the recent past? (move, job change, financial, divorce, death, faith, close friend issues)_______________________________________________________________ 2. Have you ever been hospitalized for a psychiatric condition (Suicidal, depression, anxiety, etc)?  No  Yes If yes, When/Where? ______________________________________________________ 3. Have you ever seen a: psychiatrist psychologist counselor Name:________________ Reason:______________________________________________________ 4. Does the pain interfere with your relationships?  No  Yes 5. How do you feel emotionally right now? Anxious Fearful Hopeless Angry Guilty Sad Peaceful Hopeful Other_________________________________________________ 6. Where do you find support in difficult times? Spouse Family Friend Spiritually Church Self 7. Do you have financial/social/religious/cultural concerns that might impact patient care during treatment? Yes No If yes, please explain:____________________________________________________

Patient name

DOB Top Left/HH

Rev 05-05-2011

Form 10501

Page 4 of 6

Patient Health History – page 5

Review of Systems Have you had or do you have any of the following:

Constitutional  No Problems  Fever  Night Sweats  Fatigue  Weight Loss Amount_____  Weight Gain Amount_____ Intentional Weight Change?  Yes  No Eyes  No Problems  Blindness  Blurred Vision  Double Vision  Glaucoma Ears/Nose/Throat  No Problems  Hearing loss  Difficulty Swallowing  Hoarseness Cardiovascular  No Problems  Pacemaker  Chest Pain  High Blood Pressure  Blood clots  Murmur  Rheumatic Fever  Heart Attack  Leg edema/swelling  High Cholesterol Respiratory  No problems  Shortness of Breath  Asthma  Wheezing  Emphysema  Blood in sputum  Sleep Apnea  Tuberculosis (TB)  Cough  Pneumonia

Hematology  No Problems  Blood Thinners  Anemia  Leukemia  Bleeding Disorder Neurological  No Problems  Stroke  Tremors  Dizziness  Headaches  Migraines  Seizures  Balance Problems  Paralysis  Numbness/Tingling Endocrine System  No Problems  Diabetes  Thyroid Problems  Excessive Thirst  Menopause Gastrointestinal  No problems  Abdominal Pain  Heartburn  Nausea/Vomiting  Blood in Stool  Irritable Bowel  Syndrome-IBS  Diarrhea  Hernia  Constipation  Ulcer  Jaundice Urinary tract  No problems  Frequency  Difficulty Urinating  Kidney Stones  Incontinence  Prostate problem  Kidney Disease  Renal Failure

Musculoskeletal  No Problems  Arthritis  Fractures  Gout  Osteoporosis  Fibromyalgia  Polio  Connective Tissue Disorder  Amputation Psychiatric  No problems  Sadness  Hopelessness  Compulsive Disorder  Bipolar  Schizophrenia  Anxiety  Panic Attack  ADHD  Depression Cancer  No Problems  Location ______________________  Chemotherapy  Radiation (date_______) Immunological/infectious  HIV  AIDS  Hepatitis (type __________) Other: Is there a chance that you could be pregnant?  Yes  No Are your immunizations Current? (if under 18 years old)  Yes  No

Patient Signature: _______________________________________ Date:___________________ End of Patient Section

Patient name

DOB Top Left/HH

Rev 05-05-2011

Form 10501

Page 5 of 6

Patient Health History – page 6

(Pain Management Staff to complete this page) Physical Exam Notes

ORT Score _________

Impression

Plan

Abuse/Neglect Screen:

 Yes

 No

Are there any signs of physical abuse (e.g., bruises, burns with distinctive patterns) and/or neglect (e.g., poor hygiene, lack of food and water, unmet mental health needs, etc.)?

 Yes

 No

Are there any signs of historical abuse (e.g., injuries at variance with clinical findings, injuries with questionable explanations, patient/family members reluctant to provide required information)?

 Yes

 No

Are there behavioral signs of abuse (e.g., complaints of abuse or neglect, refusal or delay in seeking treatment, repeated admission, fear of retribution)? Special Precautions While in Clinic:  Falls  Seizures  Aspirations  Environmental Orientation

 Other (Specify) : _____________________________________

Staff Signature: _____________________________________ Date & Time: ___________________

Patient name

DOB Top Left/HH

Rev 05-05-2011

Form 10501

Page 6 of 6