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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