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New Problem Questionnaire
Patient Name:
*
Full legal name
Date of Birth
*
-
Month
-
Day
Year
Date
Height:
*
Feet & Inches
Weight:
*
In pounds
Hand Dominance:
Right
Left
Ambidextrious
Preferred Language:
*
English
Spanish
Korean
Preferred Pharmacy:
Pharmacy Phone:
If unknown, leave blank
Primary Care Physician:
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New Problem Details
Please select the primary reason for your visit today:
Right
Left
Bilateral
Shoulder
Upper Arm
Elbow
Wrist
Hand
Hip:
Thigh:
Knee:
Lower Leg:
Ankle:
Foot:
Neck
Mid-Back
Lower-Back
Is this due to an injury?
*
Yes
No
Date of injury:
/
Month
/
Day
Year
If unknown, estimate the closest date.
Please explain how the injury occurred.
Please be as specific as possible.
If no injury, how long have you had this problem?
*
(# days, weeks, months, years)
Is this problem due to a work-related injury or worker's compensation claim?
*
Yes
No
Employer:
*
In this problem due to a Motor Vehicle Accident?
*
Yes
No
Date of accident:
-
Month
-
Day
Year
Date
Represented by an attorney?
*
Yes
No
Name of representative and firm:
Have you been treated for this problem in the Emergency Room or Urgent Care?
*
Yes
No
In which hospital were you seen?
Example: Gwinnett Medical Center, Northside Forsyth, etc.
Have you been treated for this problem by another doctor?
*
Yes
No
What is the name of the doctor who treated you?
Please include practice or facility name if possible.
Have you had any of the following tests for your current problem?
X-Ray
CT
MRI
Ultrasound
EMG/NCS
Lab Work
Bone Scan
Have you had any previous treatment for your current problem?
Physical/Occupational Therapy
Steroid Injections
Medications
Previous Surgery
Splints/Braces
When was your most recent steroid injection?
Approximate or if known
Was the injection administered into the affected joint/area, or was it intramuscular (via the glute)?
Into Joint
Intramuscular (via glute)
Unknown/Other
Which medications have you tried for your current problem?
When and of what nature were any previous surgeries related to this problem?
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Pain Review
Please be as specific as you can about the pain you are experiencing. You may check as many boxes as you need.
Approximately how long have you been experiencing this problem?
1+ Year(s)
1+ Month(s)
1+ Week(s)
1+ Day(s)
How many years?
Exact or approximate range
How many months?
Exact or approximate range
How many weeks?
Exact or approximate range
How many days?
Exact or approximate range
How would you rate your pain?
0
1
2
3
4
5
6
7
8
9
10
0 = no pain,
10 = most pain
What is the severity of your symptoms?
None
Mild
Moderate
Severe
How often do you experience these symptoms?
Rarely
Occasionally
Frequently
Constantly
Since onset, have your symptoms been:
Worsening
Improving
No Change
When do you experience symptoms?
Morning
Daytime
Evening
Overnight
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Have you experienced any of the following?
Aching pains
Sharp pains
Shooting pains
Weakness
Stiffness
Locking
Grinding
Popping/Clicking
Instability
Numbness/tingling
Radiation down arm
Radiation down leg
Swelling
Bruising
Warmth
Redness
Drainage
Fever
Change in bowel/bladder habits
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What causes your symptoms to WORSEN?
Cannot Identify
Standing
Sitting
Sit to Stand
Laying Down
Sleep
Weight-bearing
Exercise
Walking
Running
Squatting
Lifting
Carrying
Pushing
Pulling
Twisting
Gripping
Squeezing
Throwing
Range of motion
Getting dressed
Writing/typing
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What causes your symptoms to IMPROVE?
Cannot Identify
Ice
Heat
Elevation
Rest
NSAIDs
Narcotics
Prescription medication
Over-the-counter medication
Braces/Splints
Sling
Limited weight-bearing
Stretching
Massage
Chiropractor
Physical/Occupational Therapy
Previous injections
Previous surgery
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