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Office Use Only: Patient ID # Date: / /
HOWARD W.HARRIS, M.D. - PATIENT QUESTIONNAIRE
What activity limitations have resulted from this problem?
Type of Pain (circle all that apply):
What makes the pain worse? (circle all that apply):
What gives you relief? (circle all that apply):
PAST ILLNESSES (Circle all that apply):
Cancer (localized - one area)
Cancer (metastatic - spread)
Infection in Any Joint
PAST SURGERIES (List with approximate age, including all minor surgeries):
Date: / /
Name: DOB: - -
School/AT:________________________ Home Phone:___________________ Work:_____________________________ Cell:_________________________________
REFERRING DOCTOR:
CHIEF COMPLAINT:
Work Related: Y_____ N ______ DATE OF INJURY/ONSET OF PAIN: ______________________HEIGHT:_____________WEIGHT:_________
Describe the manner in which you were injured (please include where you were when injury occurred and be as
detailed as possible on how the injury occurred):
____________________________________________________________________________________________________________________________________________________
How often do you have the pain/discomfort: Constant / Daily / Weekly
Severity: Mild / Moderate / Intense
Please rate your pain from 1-10: While at rest: ______________ With activity:________________
Since first experiencing symptoms, are you: Improving / Unchanged / Worsening
List current treatments you have tried for this complaint (medications, injections, physical therapy,
surgery) and indicate whether they have helped or not.
Seizure Disorder