PATIENT HISTORY FORM
Today's Date: Full Name: Age: B-Day:
I go by, (name): Res. Ph.: Bus. Ph.:
Email: Soc. Sec. #: Spouse Name:
Street: City: State/Zip
FEMALES: Is there any chance that you might be PREGNANT?

Complaints

Please list your complaints below.  Start with the most significant
complaint as the number 1 chief complaint, then 2 as secondary complaint etc.
First complaint (Chief ) and location:
How did this occur?
O (Onset) Date/Time of injury or onset of symptoms:
P (Palliative) What helps relieve the pain or symptoms (rest, hot bath, exercise, other)?
Q (Quality) Sharp, dull, throbbing, boring, numb, tingling, shooting, ache, other?
R (Radiation) Where does the pain travel or is it localized?
S (Setting) Does it occur at work, home, exercise, A.M., P.M. etc.?
S (Severity) Mild, moderate, severe, very severe?
T (Timing)  Constant or intermittent or constant with varying degrees of intensity?
P (Progression) Getting, better, worse, staying the same?
Second complaint and location:
How did this occur?
O (Onset) Date/Time of injury or onset of symptoms:
P (Palliative) What helps relieve the pain or symptoms (rest, hot bath, exercise, other)?
Q (Quality) Sharp, dull, throbbing, boring, numb, tingling, shooting, ache, other?
R (Radiation) Where does the pain travel or is it localized?
S (Setting) Does it occur at work, home, exercise, A.M., P.M. etc.?
S (Severity) Mild, moderate, severe, very severe?
T (Timing)  Constant or intermittent or constant with varying degrees of intensity?
P (Progression) Getting, better, worse, staying the same?