First Name *

Last Name *

Occupation

Gender

DOB *

Height

Weight

Address *

City *

Zip / Postal code *

Email *

Would you like email appointment reminders?

Yes

No

Home Phone # *

Secondary Phone # *

Family Dr *

City

Doctor Phone #

Doctor Fax #

Referral Source *

Emergency Contact Name:

Emergency Phone # *

Relationship to patient

Name of Law Firm

Name of Lawyer

Lawyer Address

Lawyer Phone #

Lawyer Fax #

Lawyer Email

Describe your current problem:

When did the problem first begin?

Was your first episode of the problem related to a specific incident?

Yes

No

Since that time, is the problem:

Staying the same

Getting Worse

Getting Better

Please describe why/how

On a scale of 0-10 (10 being the worst), please describe the pain when it is present

Describe the nature of the pain

Describe previous treatments/exercises

What relieves your symptoms?

Social activities (excluding physical activity)

Diet/Fluid intake, specify

Physical Activity, specify

Work, specify

Other

Rate the severity of this problem from 0-10 (0 no problem, 10 the worst)

What are your treatment goals/concerns?

others, specify

Date of last physical exam

Test performed

Poor Occupation

Hours/week

On disability/leave?

Activity/Restriction?

Mental Health (Current level of stress )

High

Medium

Low

Medications - pills, injection, patch (please include start date, and reason for taking)

Describe typical position for emptying

awake hours ____ times per day

Sleep hours ____ times per night

Minutes

Hours

Not at all

The usual amount of urine passed is:

Small

Medium

Large

Times per day

Times per week

Or

The bowel movements typically are

Watery

Formed

Pellets

Other

Minutes

Hours

Not at all

If constipation is present, describe management techniques

Average fluid intake (8oz/one cup) _____________ glasses per day Of this total how many glasses are caffeinated? _______ glasses per day

Rate a feeling of organ “falling out”/prolapse or pelvic heaviness/pressure

None present

Times per month (specify related to activity or menstrual period)

with standing for __________ minutes or ___________ hours

with exertion or straining

other

What form of protection do you wear? (Please complete only one)

None

Minimal protection (tissue paper/paper towel/pantishields)

Moderate protection (absorbent product/maxi pad)

Maximum protection (specialty product/diaper)

Other

Signature of patient (or substitute decision maker)

Clear

Date