<p> Dr. Moore’s New Patient Questionnaire</p><p>Name: Age: Date:</p><p>What problem would like evaluated today (e.g. left knee pain)? ______</p><p>______</p><p>On the body diagrams use the appropriate symbols to mark where you feel the following sensations:</p><p>Numbness Pins and Needles Burning Stabbing Aching === ooo xxx /// •••</p><p>On the line below please indicate (with an X) how severe your pain is now.</p><p>No Pain------Worst possible pain 0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 – 10</p><p>When did the problem start (approximately what date)?</p><p>Did the problem result from trauma (e.g. an accident)?  yes  no</p><p>If yes, please describe: ______</p><p>Have you been evaluated by a physician or received any treatment for this problem?  yes  no</p><p>If yes, what treatments (check all applicable boxes)?  Pain medicine  Brace  Physical Therapy  Surgery  Injections  Alternative Medicine  Other______</p><p>If you have pain, what is it like (check all applicable boxes)?  Sharp  Dull  Ache  Episodic  Constant  Numb  Burning  Radiating  Stiffness  Swelling  Joint feels unstable  Other______</p><p>Patient: Page 1 of 3 What makes your symptoms worsen?  Motion  Activity  Bending  Lifting  Early morning  Running  Touch  Standing  Lying  End of day  Sports  Random  Overhead activities  Other ______</p><p>What makes your symptoms improve?  Physical Therapy  Ice  Heat  Medicine  Alternative Meds  Injections  Sitting  Lying down  Exercise  Massage  Nothing  Other______</p><p>What is your height (in feet and inches)? ______</p><p>What is your weight (in pounds)? ______</p><p>Past Medical History: Please check (X) the box next to any problems that apply to you (or the patient if completing for a child).  Heart disease  Lung disease  Kidney disease  Eye disease  Auto-immune disease  High blood pressure  Liver Disease/Hepatitis  Diabetes  Thyroid Disease  Other endocrine disease  Ulcers/Reflux  Neurological disease  Stroke  Epilepsy  Skin lesions or rash  Bleeding/Easy bruising  Sickle cell disease  Other anemia  Cancer  Arthritis  Gout or pseudogout  Depression  Other psychiatric disease  None  Other______</p><p>Past Surgical History: Please list all surgeries you have had, their dates, and the hospital where the procedure was done.  None Type of Surgery Date of Surgery Name of Hospital</p><p>Have you had any of the following diagnostic studies performed?  X-rays / radiographs  CT (computed tomography)  MRI (magnetic resonance imaging)  EMG/NCV (electromyogram / nerve conduction velocity)  Bone scan / nuclear medicine study</p><p>Who is your primary care doctor or provider?______</p><p>Medications: What medications do you take? ______</p><p>Patient: Page 2 of 3 Allergies: Please check (X) the box next to any allergies that apply to you.  No Known Allergies  Penicillin  Sulfa  Iodine  Shellfish  Cephalosporins  Other antibiotics, medications, foods, or dyes:______</p><p>Do you have any difficulty taking anti-inflammatory medicines (e.g. Motrin)?  Yes  No  Unknown</p><p>Review of Symptoms: Please check (X) the box next to any problems that apply to you (or the patient if completing for a child).  Fever or Chills  Difficulty sleeping  unintended weight loss  Heat or Cold Intolerance  Change in Gait  Weakness  Loss of control of bowel  Loss of control of bladder  Numb arm or leg  Dizzy or light-headed  Chest Pain  Shortness of breath  Night pain  Endocrine/hormonal  Psychiatric/emotional  Other difficulties:______</p><p>Family History:  Cancer  Diabetes  Heart Disease  Stroke  Bleeding Problems  Sickle cell anemia  Sudden death  Arthritis  Other</p><p>Social History: Tobacco use:  no  yes if yes, packs per day_____, years of use _____ Alcohol use:  no  yes if yes, amount per week______. Work status:  employed  unemployed  disabled  retired What is your occupation?______Marital status:  single  married  divorced  separated  widow/widower Handedness:  right  left  ambidextrous</p><p>Developmental History: (complete if patient is an infant or child) Did pregnancy go to full term?  yes  no  unknown Normal birth / normal first exam?  yes  no  unknown Normal motor developmental milestones?  yes  no  unknown Normal verbal developmental milestones?  yes  no  unknown Are immunizations up to date?  yes  no  unknown Is the child generally healthy?  yes  no  unknown</p><p>If you answered “no” to any of the above questions, please elaborate below: ______</p><p>Doctor’s Notes:</p><p>Patient: Page 3 of 3</p>