Personal Health Questionnaire

Thank you for taking the time to fill out this questionnaire.
This information will help us prepare for your visit and will be kept confidential.
Read our privacy policy.

Personal Information

First Name*

Date of Birth* [example: 1/1/1984]
  

Physician

Last Name*

e-Mail*

Physician Fax

Injury History

Briefly describe your current problem/problems.

When did your condition/injury begin?

What caused your condition/injury?
[select all that apply]

Sudden/Unknown
Fall
Injured at work
Twisting/bending
Other
Gradual
Motor Vehicle
Lifting/pulling
During sports

Have you been given a diagnosis? If so what is your diagnosis?

Have you had diagnostic tests for this condition?
Yes
No

If so, which of the following tests have been performed?
[select all that apply]

X-Ray
CT
Electromyogram
Arthrogram/Sonogram
MRI
Discogram
Myelogram
Other

Have you received treatment for this condition?
Yes
No

Which of the following treatments have you received?
[select all that apply]

Electrical Stimulation
Ultrasound
Manipulation
Traction
Strength Training
Splinting
Lontophoresis
Biofeedback
Cold/Hot Packs
Massage/Soft Tissue
Trigger Point Massage
Aerobic Exercise
Aquatic Therapy
Work-Hardening
TENS
Other

Which, if any, of the treatment techniques you selected helped your condition/injury?

Which, if any, did not help your condition/injury?

Have you had surgery for your condition?
Please describe the surgery and give approximate dates.

Are your symptoms constant, do they come and go?

What activities aggrivate your symptoms?
[select all that apply]

Exercise (During)
Exercise (After)
Lying Down/Sleeping
Computer Work
Descending Stairs
Bending Forward
Bending Backward
Bending Left
Bending Right
Sitting
Standing
Writing
Lifting
Walking
Climbing Stairs
Running
Driving
Other

How do you decrease symptoms?
[select all that apply]

Nothing
Physical Therapy
Manipulation Chiro/Osteopathic
Injections For Pain
Anti-Inflammatories
Pain Medication
Muscle Relaxant
Brace/Splint
Stand
Walk
Ice/Heat
Lie Down
Sit Down
Other

Pain History

Rate your pain at rest on a scale of 0-10.
(0=no pain 10=worst pain)

Rate your pain w/activity on a scale of 0-10.
(0=no pain 10=worst pain)

Is your pain worse in the:
[select all that apply]

Morning
Night
Afternoon
Evening
Same
Varies

Describe your pain/symptoms.
[select all that apply]

Sharp
Burning
Stabbing
Localized (Small Area)
Diffuse (Large Area)
Radiating (Down Arm Or Leg)
Numbness/Tingling
Pins/Needles
Dull/Aching

Please list any current medical condition/conditions you have.

Please list your current hobbies, sports, or recreational activities.

Does your condition prevent participating? If yes, how so?

* Denotes Required Fields






Functional Health and Wellness
852 W. Madison St., Oak Park, IL 60302 | Phone: 708.445.FXNL(3965) | Email: info@fxnlhealth.com