Patient History and Pain Intake Form (HPI)

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Full Name

Nombre

Apellido

Date of Birth

E-mail

Do you have any medication allergies?

Yes No

Please list your allergies and briefly describe the reaction you have:

Do you have any food allergies?

Yes No

Please list your food allergies and briefly describe the reaction you have:

Do you have allergies to IV Contrast or Iodine?

Yes No Not sure

Please explain:

As a new patient, our office requires you to provide a list of your current medications. Please select the method that works best for you.

Type it into this form Upload a photo of the list Bring a printed copy to the visit Ask my pharmacy to send it

You can also upload your medication list

Max 10 MB per file

How tall are you?

What is your current weight?

If other, please specify

Other

If other, please specify

Tobacco Status

How much do you smoke?

If other, please specify

Comment

When did you stop smoking?

Have you ever used smokeless tobacco?

How long have you used tobacco products?

Comment

Have you ever used e-cigarettes or vapes?

Comment

How often do you drink alcohol?

How long have you been consuming alcoholic beverages?

Have you ever used illicit drugs?

Please explain

Have you ever had a problem with substance abuse?

Please explain

Are you currently employed?

Yes No

What is your occupation?

What is your employment status?

Other

Are you disabled?

Yes No

Are you retired?

Yes No

Is this a work-related injury?

Yes No

Approximate month and year of injury and brief description:

Have you experienced a similar pain complaint prior to this injury?

Is there an active legal case/atty or worker's injury claim going on?

Yes No

Is this an auto accident-related injury?

Yes No

Approximate month and year of injury and brief description:

Have you experienced a similar pain complaint prior to this accident?

Do you have difficulty walking or climbing stairs?

Yes No

Do you live alone or with others?

I live alone I live with others

If with others, please say who:

Marital Status

Number of Children

Do you have any implanted mechanical or battery operated devices, not including any joint replacements?

Yes No

If Yes, please specify using the space below and bring your device card at the time of your appointment to be scanned into your chart

Please select surgical procedures you've had in the past with their approximate dates and the names of the performing surgeons, if known:

Please list any other surgical procedures you've had in the past with their approximate dates and the names of the performing surgeons, if known:

Have you ever had a Mammogram?

Yes No Not sure

Approximate month and year of Mammogram

Have you ever had a Colonoscopy?

Yes No Not sure

Approximate month and year of Colonoscopy

Have you had a Flu Vaccine in the past 12 months?

Yes No Not sure

Approximate date of Flu Vaccine

Have you had a Pneumonia Vaccine in the past 12 months?

Yes No Not sure

Approximate month and year of Pneumonia Vaccine

Are you feeling sick today? Includes any NEW symptom(s) among those listed previously that are NOT due to another health problem

Yes No

Have you tested positive for COVID-19 in the past 10 days?

Yes No

In the last 10 days, have you been exposed to someone who has tested positive for COVID-19?

Yes No

Have you had or are you scheduled for the Covid-19 vaccines?

Vaccination completed Partially vaccinated Appointment scheduled No

Date of Covid-19 vaccine

Past Medical History:

What type of cancer?

Do you currently have an active infection/rash?

Yes No

What medications (antibiotics) are you taking for that?

Name of the prescriber

Prescriber contact number

Are you currently on blood thinners?

Yes No

Name of the prescriber

Prescriber contact number

Are you Left or Right Handed?

Right handed Left handed Ambidextrous

Section

Main complaint (e.g. back pain)

Where is the exact location of your pain today?

Does your pain radiate into your Arm(s) or Leg(s)?

Yes No

Where does your pain radiate into?

Please describe how your pain radiates

Approximate month & year the pain started

In your opinion, can you specify any events that could have caused your pain? Please describe the event briefly (with approximate date):

Which of the following activities are you not able to perform?

Do you experience any of the following?

Location where you experience the above symptom(s):

When is your pain worse?

In the morning In the afternoon In the evening During the night After physical activity At rest Constant through the day

What makes your pain better?

Pain scale: 1 means minimal discomfort and 10 means the worst pain imaginable.

Rate your pain at its worst:

1-2 (mild) 3-4 (mild to moderate) 5-6 (moderate) 7-8 (severe) 9-10 (unbearable)

Rate your pain on average:

1-2 (mild) 3-4 (mild to moderate) 5-6 (moderate) 7-8 (severe) 9-10 (unbearable)

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Have you previously tried or are you currently taking any over-the-counter medications to treat your pain? Example: acetaminophen, Aleve, Advil...

Yes No Not sure

Have you taken any prescription medication for your pain?

Yes No Not sure

Section

Have you tried physical therapy for this pain?

Yes No Not sure

Are you currently attending physical therapy for this pain?

Yes No Not sure

Approximate date tried

Number of weeks tried

Approximate % of relief

Have you tried home exercises for this pain?

Yes No Not sure

Are you currently in a home exercise program for this pain?

Yes No Not sure

Approximate date tried

Number of weeks tried

Approximate % of relief

Have you tried chiropractic treatment for this pain?

Yes No Not sure

Are you currently having chiropractic treatments?

Yes No Not sure

Approximate date tried

Number of weeks tried

Approximate % of relief

Have you tried acupuncture for this pain?

Yes No Not sure

Are you currently having acupuncture treatments?

Yes No Not sure

Approximate date tried

Number of weeks tried

Approximate % of relief

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Have you tried TENS unit for this pain?

Yes No Not sure

Are you currently using a TENS unit?

Yes No Not sure

Approximate date tried

Number of weeks tried

Approximate % of relief

Have you tried heat for this pain?

Yes No Not sure

Approximate date tried

Number of weeks tried

Approximate % of relief

Have you tried ice for this pain?

Yes No Not sure

Approximate date tried

Number of weeks tried

Approximate % of relief

Other Treatment modalities you have tried

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Have you tried spinal injection(s) for this pain?

Yes No Not sure

Have you had spine surgery for this pain?

Yes No Not sure

Approximate date of surgery

Type/Body location of surgery (if known)

Name of doctor (if known)

Percentage of relief

Duration of relief

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Diagnostic studies already carried out for this pain

Have you had MRI Scan for this pain?

Yes No Not sure

Region of the body where MRI was performed

Have you had CT Scan for this pain?

Yes No Not sure

Region of the body where CT Scan was performed

Have you had X-ray for this pain?

Yes No Not sure

Region of the body where X-ray was performed

I have not had ANY diagnostic tests for my current pain complaint

Yes No

What are your expectations for your visit?

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By signing I confirm the information given is correct to the best of my knowledge.

Date

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