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Have you ever had cancer?Does your pain ever wake you from a sound sleep?Are you losing weight now without trying?Are you coughing up blood or noticing it in your stools or urine?Have you had any loss of bladder or bowel control?Have you lost consciousness or had double vision recently?Are you seeing any other doctor now for any reason?Yes___ No___Yes___ No___Yes___ No___Yes___ No___Yes___ No___Yes___ No___Yes___ No___Note: __________________________________________________________________________Are you taking any medications or over-the-counter drugs?Yes___ No___Please indicate type (aspirin, etc.) ___________________________________________________What was the date of onset of your last menses? ________________________________________SOCIAL HISTORYSmoker _______ Yes or_____ No, If Yes, How many packs _____________________________Alcohol _______ Yes or_____ No, If Yes, How much __________________________________FAMILY HISTORYDid your mother or father have any of the following:Put an M for mother, F for father, and B for both( )High Blood Pressure ( )Ulcer or Stomach Problems( )Heart Attack ( )Stroke( )Emphysema ( )Arthritis-Rheumatism( )Seizures-Convulsions ( )Mental Illness( )HIV Positive ( )Thyroid Disease( )Asthma ( )Circulation Problems( )Diabetes ( )Cancer( )Kidney Disease ( )Osteoporosis( )PacemakerComments: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SHOW AREA(S) OF PAIN OR UNUSUAL FEELINGMark the areas on this body where you feel the described sensations.Use the appropriate symbols.Mark areas of radiation.Include all affected areas.Numbness Pins & Needles Burning Aching Stabbing- - - - - OOOOO xxxxx ***** / / / / /- - - - - OOOOO xxxxx ***** / / / / /- - - - - OOOOO xxxxx ***** / / / / /Please mark on the pain scale from Zero to 10 the pain you feel with this condition. 10 being theworst pain you have felt with this condition.Pain ChartNeck-Shoulder-Arm PainOn a scale of zero to 10, I rate mydiscomfort as follows(___________________)0 10no pain severe painMid Back PainOn a scale of zero to 10, I rate mydiscomfort as follows(___________________)0 10no pain severe painright left left rightLow Back and Leg PainOn a scale of zero to 10, I rate mydiscomfort as follows(___________________)0 10no pain severe painDate: _____________________Signature ______________________________________
Page 5: PATIENT NAME ______________________

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