Do you exercise? No regular exercise 1-2 times a week 3-4 times a week 5-7 times a week □ □ □ □ Cardiovascular Stretching Weight Machine Free Weights Sports (type) □ □ □ □ □ What is your present stress level? No stress Minimal stress Moderate stress Greatly stressed □ □ □ □ Is your problem affecting your ability to work or do other routine daily activities? No effect Have some limited physical restrictions, but can function Cannot work □ □ □ Need some assistance with daily activities Cannot function without assitance Disabled □ □ □ Do you have or have you ever had any of the following disease or conditions? Heart Problems Seizures/ epilepsy Arthritis □ □ □ High/Low Blood Pressure Diabetes Artificial Bones □ □ □ Breathing or Problems Kidney problems Artificial joints □ □ □ Asthma Glaucoma Immune Diseases □ □ □ Stroke Ulcers/ Colitis Shingles □ □ □ Severe Headaches Anemia HIV/AIDS □ □ □ Fainting Cancer ( Type:________ ) Alcohol/Drug □ □ □ Psychiatric problems □ Are you currently taking any medications ? Heart meds Pain Killers (including Aspirin) Muscle relaxers Anti-depressants □ □ □ □ Blood thinners Insulin Vitamins Others □ □ □ □ Are you allergic to any medications? Y or N If yes, please list: Please list any surgical procedures you have had with approximate dates: Tobacco use: Past Present Occasional Moderate Heavy □ □ □ □ □ Alcohol use: Past □ Present □ Occasional □ Moderate □ Heavy □ Caffeine Use: Past Present Occasional Moderate Heavy □ □ □ □ (Coffee, tea, soft drinks) □ For Women only, are you: Pregnant (if yes, how far along are □ you?) Nursing □ Please shade in the figures below where you have pain, or other symptoms:
Do you exercise? □ No regular exercise □ 1-2 times a week □ 3-4 times a week □ 5-7 times a week □ Cardiovascular □ Stretching □ Weight Machine □ Free Weights □ Sports (type) What is your present stress level? □ No stress □ Minimal stress □ Moderate stress □ Greatly stressed Is your problem affecting your ability to work or do other routine daily activities? □ No effect □ Have some limited physical restrictions, but can function □ Cannot work □ Need some assistance with daily activities □ Cannot function without assitance □ Disabled Do you have or have you ever had any of the following disease or conditions? □ Heart Problems □ Seizures/ epilepsy □ Arthritis □ High/Low Blood Pressure □ Diabetes □ Artificial Bones □ Breathing or Problems □ Kidney problems □ Artificial joints □ Asthma □ Glaucoma □ Immune Diseases □ Stroke □ Ulcers/ Colitis □ Shingles □ Severe Headaches □ Anemia □ HIV/AIDS □ Fainting □ Cancer ( Type:________ ) □ Alcohol/Drug □ Psychiatric problems Are you currently taking any medications ? □ Heart meds □ Pain Killers (including Aspirin) □ Muscle relaxers □ Anti-depressants □ Blood thinners □ Insulin □ Vitamins □ Others Are you allergic to any medications? Y or N If yes, please list: Please list any surgical procedures you have had with approximate dates: Tobacco use: □ Past □ Present □ Occasional □ Moderate □ Heavy Alcohol use: □ Past □ Present □ Occasional □ Moderate □ Heavy Caffeine Use: (Coffee, tea, soft drinks) □ Past □ Present □ Occasional □ Moderate □ Heavy For Women only, are you: □ Pregnant (if yes, how far along are you?) □ Nursing Please shade in the figures below where you have pain, or other symptoms:
New_Patient_Packet_new_new.docx