New Patient Questionnaire

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Liza Maniquis-Smigel, MD LLC

Physical Medicine & Rehabilitation

Spine, Sports & Electrodiagnostic Medicine

Prolotherapy

New Patient Quetioniere

Name* Height* Weight* Age* Occupation* 1. What Is the Reason For Your Visit?

2. Please See Diagram Below

Look at the following diagram and list the areas where your pain / problem occurs: IF None pleasE indicate NONE IN THE BOX BELOW

RIGHT FRONT List All Pain Or Problems*

LEFT FRONT List All Pain Or Problems*

RIGHT BACK List All Pain Or Problems*

LEFT BACK List All Pain Or Problems*

3. When did you first notice the problem beginning? (month/day/year)

4. What did you believe caused the problem? Was there an incidence of trauma or accident?

5. How much time each day do you experience pain?* 100% (all day & night) 75% (most of the day & night) 50% (half of the day & night) 25%(part of the day & night) not everyday

6. Which terms best describe the pain?* Achy Dull Sharp Nagging Pins and Needles Burning Stabbing Other (Please explain below)

Other

7. What helps you with the pain (RELIEVING FACTORS)?

8. What factors aggravate or make the pain worse?

9. Did you lose any strength and sensation? If so, Please describe:

10. Please list all the doctors you have seen for this problem:

11. Please list all the diagnostic tests you have had for this problem:

12. Have you had operations or procedures for this problem? If so, please list all the operations you have undergone and their dates:

13. Have you had physical therapy for this problem? If so, please list where, when and physical modalities used:

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