Patient Questionnaire
Part 1: Demographics
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status
*
Single, not in a relationship
Single with significant other
Married
Divorced
Widowed
Children - Total number
*
0
1
2
3
4
5
Dependents (children, other family members) living in the home
*
0
1
2
3
4
5
Patient Questionnaire
Part 2: Habits
Do you exercise (for at least 20-30 minutes)?
*
No
No, due to pain
Yes, 1-2 times per month
Yes, 1-2 times per week
Yes, 3 or more times per week
Yes, every day
Do you use tobacco?
*
No
Yes, less than a pack a day
Yes, more than one pack a day
Yes, chewing tobacco
Are you interested in help to stop using tobacco?
*
Yes
No
Do you drink alcohol?
*
Never
Yes, rarely (1-2 times a month)
Yes, 1 time per week.
Yes, 2-3 times per week.
Yes, daily.
Please check all that you are CURRENTLY using (within the last month):
*
Marijuana
Amphetamine, methamphetamine
Cocaine
Heroin
Ecstacy
Prescription medications NOT prescribed to me
NONE
Please check all that you have used within the last YEAR:
*
Marijuana
Amphetamine, methamphetamine
Cocaine
Heroin
Ecstacy
Prescription medications NOT prescribed to me
NONE
Do you drink caffeinated beverages?
*
No
Yes, 0-1 cups daily
Yes, 2-3 cups daily
Yes, 3 or more cups daily
Which caffeinated beverages do you drink regularly?
*
Coffee
Tea
Soda / Pop
Energy Drinks
NONE
Patient Questionnaire
Part 3: Educational and Work History
Are you currently in school?
*
Yes, full time.
Yes, part time.
No.
When was the last time you were in school (year)?
*
What is the highest level of schooling you have finished?
*
attended High School
graduated High School
GED
Some college
Two year degree (Assoc)
4 year degree (BA/BS)
Some graduate school
Master's Degree
Ph.D or MD
Are you currently employed?
*
Yes, Full time.
Yes, part time.
No, retired.
No, disability.
No, unemployed.
When was the last time you worked if not currently working (year)?
*
What has been your primary occupation? What sort of work have you done?
*
Have you ever served in the military?
*
Yes, active duty.
Yes, reserves.
No.
Which branch of the military did you serve under?
Army
Navy
Air Force
Marines
Coast Guard
What years did you serve (year to year)?
Did you ever experience combat while serving?
Yes
No
Were you injured during your time of service?
Yes
No
Do you receive disability benefits from your time of service?
Yes
No
Patient Questionnaire
Part 4: Surgical History
Please list all surgeries you have had (surgery type, year):
Submit
Should be Empty: