George Caldwell MEDICAL QUESTIONNAIRE George Caldwell MEDICAL QUESTIONNAIRE Name First Last Date MM slash DD slash YYYY 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 1 2 3 4 5 6 7 8 9 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) Bleeding disorder Sciatica/Radiating pain High blood pressure (hypertension) Seizures Diabetes Angina Ulcers Back pain/disc disorder MRSA Infection Cancer Gout Sickle cell disease Asthma Hepatitis/Jaundice Unusually high fever HIV, AIDS, TB Emphysema, lung disease, (COPD) Recent cold Blood clots Kidney disease Thyroid disease Phlebitis Mitral valve prolapse Rash/skin lesion Eye disorder Arrhythmia (i.e. atrial fibrillation) Psychological disorders Heart attack (MI) Date: Yes Date: Other: 11. Review of Symptoms: Do you currently have any of the following? (check all that apply) Fevers, night sweats Bladder problems Sore throat, earache Unexplained weight loss Pain when urinating Urinary infections Chest pain Difficulty breathing Stomach pain Vision difficulties Skin rash Depression/Anxiety 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: