History and Physical Form
Patient Name: *
Your answer
Contact Phone Number: *
Your answer
Referred by: *
Your answer
Referring Provider Contact information: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Sex: *
Have you or will you be seeking an attorney? *
When did the problem begin? *
Your answer
If this was an injury describe what happened? *
Your answer
Is this work related? *
If yes, what is your claim number?
Your answer
Employer/Current Occupation: *
Your answer
When did you first seek medical attention? Please include description of treatment. *
Your answer
Who has treated you for this injury/condition?
Your answer
On a scale of 0-10, how severe is your pain TODAY? *
0=No pain 10= Extreme pain
Please select the numbers in the diagram above that correspond to your pain
Describe the problem *
Required
Select the following that you have had completed for your problem you are being treated for today: *
Required
Please describe above:
Include date, body part, and side(R/L):
Your answer
Do you take any medications for this injury? If so, please include medication name, dosage, and frequency.
Your answer
Describe current complaints: *
Your answer
Have you ever had similar problems? *
If so, when?
Your answer
Are you currently working? *
If so, full or part time?
Do you exercise regularly? *
If so, how often?
Your answer
Do you smoke cigarettes? *
If so, how many per day
Your answer
Do you drink alcohol? *
If so, how often?
include number of daily drinks, weekly drinks, or if special occasions
Your answer
Do you use mood-altering drugs? *
Height *
Your answer
Weight *
Your answer
Shoe Size *
Your answer
During the past week, how stiff was your extremity? *
During the past week, how swollen was your extremity? *
During the past week, how painful was your extremity when walking on a flat surface? *
During the past week, how painful was your extremity when going up or down stairs? *
During the past week, how painful was your extremity when lying in bed at night? *
Extremity pain level: *
The following make the condition worse: *
Required
My ability to get around most of the time in the last week is described as:
The level of difficulty I endured when taking off my shoes and socks in the last week was: *
My General State of Health is: *
Prior Surgeries and dates:
Your answer
Prior treatment for condition and dates:
Your answer
Current Medications you are taking:
Your answer
Are you allergic to any medications? *
If yes, please list medication and reaction
Your answer
I have the following medical problems:
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