SEACOAST AREA PHYSIATRY, P.C. CLINICAL QUESTIONNAIRE
Please complete this form as accurately and completely as possible as it will become part of your permanent medical record.
DATE_____________NAME_____________________________________ DATE OF BIRTH____________ AGE_______ R/L HANDED
PLEASE DESCRIBE THE REASON(S) FOR TODAY’S VISITS.
1. _________________________________________________________________________________
2. _________________________________________________________________________________
DATE OF ONSET/INJURY OF SYMPTOMS ______________ HAVE YOU EVER HAD SIMILAR SYMPTOMS PRIOR? YES NO
UNDER WHAT CIRCUMSTANCES DID YOUR CURRENT SYMPTOMS OCCUR?
WORK RELATED
MOTOR VEHICLE ACCIDENT
OTHER_____________________
HAVE YOU EVER BEEN SEEN BY ONE OF OUR PROVIDERS AT SEACOAST AREA PHYSIATRY? YES NO
WHO IS YOUR PRIMARY CARE/ FAMILY PHYSICIAN? _________________________________
WHO REFERRED YOU FOR TODAY’S EVALUATION? (Please identify by name)
PHYSICIAN _______________________________ OTHER _____________________________________
HOW DID YOU HEAR ABOUT US? RADIO/ADVERTISEMENT OTHER _____________________________________
PLEASE PLACE A MARK ON THE SCALE BELOW THAT BEST DESCRIBES YOUR AVERAGE LEVEL OF PAIN.
NO PAIN 0________________________________________________________________ 10 WORST POSSIBLE PAIN
ARE YOUR SYMPTOMS: CONSTANT? YES NO
INTERMITTENT? YES NO
RELATED TO ACTIVITY? YES NO
PLEASE LIST THOSE ACTIVITIES THAT INCREASE OR DECREASE YOUR SYMPTOMS
INCREASE DECREASE
_______________________________ ____________________________________
_______________________________ ____________________________________
_______________________________ ____________________________________
ARE YOUR SYMPTOMS: GETTING WORSE? GETTING BETTER? STAYING THE SAME?
PLEASE STATE THE MAXIMUM AMOUNT OF TIME YOU TOLERATE EACH OF THE FOLLOWING ACTIVITIES:
SITTING________ STANDING______ WALKING______
DRIVING________ PASSENGER IN VEHICLE ______
HAVE YOU HAD PRIOR DIAGNOSTIC TESTING RELATED TO YOUR CURRENT COMPLAINT? YES NO
Please check the following tests that you have had done: X-ray MRI CT scan EMG/NCS Bone scan Other
PLEASE BRING ALL OF THE TESTS (FILMS AND REPORTS) ABOVE TO YOUR APPOINTMENT.
Provider’s
Initial
2
PLEASE CHECK AS MANY OF THE FOLLOWING HEALTH PROBLEMS THAT YOU NOW HAVE OR HAVE HAD
Anemia
Cyst
Lung Disease
Tuberculosis
Other psychiatric issues
Blood disease
Back problems
Headaches
Hepatitis
Arthritis
High Blood Pressure
Disc problems
Migraine
Liver disease
Bursitis
Diabetes
Multiple Sclerosis
Bone
Gallbladder Disease
Ganglion
Thyroid Disease
Head Injury
Joint Disease
Heart Disease
Loss of sight
Allergy
Stroke
Amputation foot
Heart Attack
Ulcer
Hay Fever
Phlebitis
Amputation leg
Kidney trouble
Seizures
Asthma
Blood clot
Amputation arm
Bladder trouble
Epilepsy
Cancer
High Cholesterol
Cerebral palsy
Anxiety
Ulcerative colitis
Tumor
Hernia
Parkinson’s Disease
Depression
Crohn’s
Fibromyalgia
PLEASE LIST ANY OPERATIONS/SURGERY YOU HAVE HAD
_________________________________________________________ DATE_____________________________
_________________________________________________________ DATE_____________________________
_________________________________________________________ DATE_____________________________
PLEASE LIST YOUR CURRENT MEDICATIONS INCLUDING PRESCRIPTION MEDS AND ALL OVER THE COUNTER MEDICATIONS OR
SUPPLEMENTS ALONG WITH THE DOSAGE AND HOW OFTEN YOU TAKE EACH DAY.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
DO YOU HAVE MEDICATION ALLERGIES? YES NO IF YES, PLEASE SPECIFY MEDICATION ALLERGIES TYPES OF
REACTIONS BELOW
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
FAMILY HISTORY AGE AGE AT DEATH MEDICAL CONDITIONS
Mother ______ _______ __________________________________________________________
Father ______ _______ __________________________________________________________
Brother ______ _______ __________________________________________________________
Sister ______ _______ __________________________________________________________
Other ______ _______ __________________________________________________________
Children ______ _______ __________________________________________________________
SOCIAL HISTORY: ARE YOU SINGLE, DIVORCED, MARRIED, WIDOWED, OR LIVING WITH PARTNER?
DO YOU HAVE ANY CHILDREN? YES NO
TOBACCO USE: ARE YOU A CURRENT SMOKER
FORMER SMOKER
NEVER SMOKER
CURRENTLY CHEW TOBACCO
FORMERLY CHEWED TOBACCO
IF CURRENT SMOKER, HOW MANY/DAY? _______ x # of YEARS? ______
DO YOU DRINK ALCOHOL, BEER OR WINE? YES NO TYPE? _______________________ HOW MUCH PER DAY/WEEK?
HAVE YOU EVER USED ILLICIT OR RECREATIONAL DRUGS? YES NO
CURRENT WORK STATUS (PLEASE CIRCLE ONE)
FULL TIME PART TIME UNEMPLOYED RETIRED DISABLED OTHER ___________________
IF RETIRED OR DISABLED DATE OF RETIREMENT/DISABILITY ___________________
INTERESTS/HOBBIES ______________________ REGULAR EXERCISE YES NO
I verify, to the best of my ability, that the information I have provided is accurate and complete.
________________________________________________________ ______________________
Patient Signature Date
Provider’s
Initial
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