George Caldwell MEDICAL QUESTIONNAIRE

Name

First Last

Date

Date of Birth:

Age:

Sex:

Male
Female

Occupation:

Employer:

Who referred you to us?

Primary Care Physician:

Pharmacy Name:

Pharmacy Phone:

Pharmacy Address:

1. Presenting Complaint:

Affected Side:

Left
Right

Body Area:

Knee
Shoulder
Elbow
Hip
Ankle/foot
Hand/wrist
Spine

Other:

2. Pain Scale: 0- no pain and 10- worse pain (check one)

From 1 to 10

3. How long have you had the problem?

Have you experienced this before?

What makes the problem worse?

What makes the problem better?

4. Was this a result of an injury?

Yes

If yes, describe how it happened

5. Is this a workman’s compensation injury?

Yes

(if no, advance to question #6)

If yes, please answer the following:

Job Title:

Date of Injury:

Are you:

Off work
Modified duty
Full duty

6. Is your problem getting:

Worse
Better
the same

7. What studies have been done?

MRI
Bone Scan
CT

Other

8. Have you had injections?

Yes

If so, where?

How much did it help?

For how long?

9. How would you describe the pain?

Quality:

Dull
Throbbing
Sharp

Timing:

Intermittent
Constant (even at rest)
Related to activity

Severity:

Mild
Moderate
Severe

Associated symptoms:

Heat
Numbness
Weakness
Burning
Giving away
Catching/Locking

Other:

10. Past Medical History: Have you had any of the following? (check all that apply)

Heart attack (MI) Date:

Yes

Date:

Other:

11. Review of Symptoms: Do you currently have any of the following? (check all that apply)

Numbness: (location)

Other:

12. List Allergies:

13. List current medications (give doses, Include any over-the-counter or herbal meds)

14. List any surgery or hospitalizations that you have had (give dates):

15. Social History:

Marital Status:

Single
Married
Divorced
Widow

Tobacco

Nonsmoker
Previous smoker
Current smoker

Previous smoker (cessation date):

Current smoker packs per day

Alcohol

None
Rare
Social
Frequent

History of substance abuse:

Yes

If so, what?

16. Family History (check all that apply)

Arthritis
Diabetes
Problems with anesthesia
Obesity
Cancer
NONE

Other:

George Caldwell

Our Locations

Broward County

Marathon

Key West