DARROCH
BRAIN AND SPINE INSTITUTE OF DOCTORS MEDICAL CENTER
4016 DALE RD. MODESTO, CA 95356
PHONE (209) 571-0288
PATIENT INFORMATION
NAME (Last, First, Middle) BIRTHDATE (MM/DD/YYYY) AGE SEX MARITAL STATUS
MAILING ADDRESS CITY STATE ZIP CODE
HOME PHONE CELL PHONE ALTERNATE PHONE
( ) ( ) ( )
SOCIAL SECURITY NUMBER E-MAIL ADDRESS EMERGENCY CONTACT NAME / PHONE NUMBER
REFERRING PHYSICIAN
REFERRING DOCTOR NAME ADDRESS PHONE NUMBER
( )
PRIMARY CARE PHYSICIAN NAME ADDRESS PHONE NUMBER
( )
PRIMARY INSURANCE
NAME OF INSURANCE COMPANY ID/POLICY# GROUP #
SUBSCRIBER NAME RELATIONSHIP SUBSCRIBERS EMPLOYER
SUBSCRIBERS SOCIAL SECURITY NUMBER SUBSCRIBERS DATE OF BIRTH CO-PAY AMT
$
SECONDARY INSURANCE (IF APPLICABLE)
NAME OF INSURANCE COMPANY ID/POLICY# GROUP#
SUBSCRIBERS NAME RELATIONSHIP SUBSCRIBERS EMPLOYER
SUBSCRIBERS SOCIAL SECURITY NUMBER SUBSCRIBERS DATE OF BIRTH CO-PAY AMT
$
WORKERS COMPENSATION INFORMATION
WORK COMP CARRIER NAME CARRIER’S ADDRESS
CLAIM # DATE OF INJURY EMPLOYER AT TIME OF INJURY
ADJUSTER’S NAME ADJUSTER’S PHONE NUMBER ADJUSTER’S FAX NUMBER
I hereby consent to allow, use, disclose and furnish photocopies of my records to insurance companies, physicians, hospitals, medical equipment/supply companies,
physical therapists as needed for my medical care and to use information for purposes related to treatment, payment or healthcare operations. I understand that I
am ultimately responsible for payment of all charges incurred in this office regardless of coverage. This authorization is valid until revoked. The above information
furnished by me is true and accurate to the best of my knowledge.
PATIENT SIGNATURE:___________________________________________ DATE:________________________________
PLEASE COMPLETE THIS MEDICAL QUESTIONNAIRE TO THE BEST OF YOUR KNOWLEDGE
PATIENT NAME:________________________________________________ DATE:________________________________
DATE OF BIRTH:_____________________ AGE:________________ SEX: □ Male □ Female
CURRENT CHIEF COMPLAINT:
Main complaint or reason for consultation:_______________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
When did your pain start?:______________________ The pain began: □ Suddenly □ Gradually □ Chronic
Did the symptoms arise as a result of an injury? □ Yes □No If yes, date of injury?:___________________________
If you were injured, is the injury related to: □ Job/Industrial □ Motor Vehicle Accident □ Other:____________
TREATMENT YOU HAVE RECEIVED TO DATE:
□ Physical Therapy How long?:_______________________________ Did it help?_____________________
□ Chiropractic Treatment How long?________________________________ Did it help?_____________________
□ Medications: Name of medications___________________________________________________________________
_________________________________________________________________________Did they help?_____________
□ Injection Therapy: □ Epidural injection: When?_________How many?___________ Did it help?:_____________
□ Facet blocks: When?_________How many?___________ Did it help?:_____________
□ Trigger points : When?_________How many?___________ Did it help?:_____________
□ Other:______________________When?___________ Did it help?:______________________
Have you ever had any of these tests: □ MRI of the brain or spine: When?:_______________________________
□ CT scan of the brain or spine: When?:_______________________________
□ Myelogram: When?:_______________________________
□ EMG/NCV: When?:_______________________________
□ EEG: When?:_______________________________
□ X-rays: When?:_______________________________
1
MEDICAL HISTORY:
CURRENT MEDICAL PROBLEMS: (check all that apply)
□ AIDS/HIV □ Diabetes - Type or Type II □ Hypertension □ Pancreatitis
□ Arthritis/Gout □ Depression □ Irregular Heartbeat □ Seizures
□ Asthma □ Emphysema/COPD □ Liver or Kidney Problems □ Stroke
□ Bleeding Condition □ Glaucoma □ Neuropathy □ Thyroid Disease
□ Blood clots / DVT □ Heart Disease/Heart attack □ Osteoporosis □ Ulcers or Reflux
□ Cancer: □ Hepatitis □ Pacemaker or Heart Valve □ Other:__________________
Type/location:______________________________
SURGICAL HISTORY: (please list all surgeries and dates)
1.______________________________________________ 5.____________________________________________
2.______________________________________________ 6.____________________________________________
3.______________________________________________ 7.____________________________________________
4.______________________________________________ 8.____________________________________________
Other illnesses requiring hospitalization: (include dates)
1.______________________________________________ 4.____________________________________________
2.______________________________________________ 5.____________________________________________
3.______________________________________________ 6.____________________________________________
MEDICATIONS YOU ARE CURRENTLY TAKING: (please include dosage, supplements and over the counter drugs and
why you are taking them)
1._________________________________________________________________________________________________
2._________________________________________________________________________________________________
3._________________________________________________________________________________________________
4._________________________________________________________________________________________________
5._________________________________________________________________________________________________
6._________________________________________________________________________________________________
7._________________________________________________________________________________________________
8._________________________________________________________________________________________________
Do you have any medication allergies? □ Yes □ No
If yes, please list allergies:_____________________________________________________________________________
Are you allergic to ADHESIVE TAPE? □ Yes □ No Are you allergic to LATEX? □ Yes □ No
Are you allergic to IODINE? □ Yes □ No Are you allergic to Gadolinium? □ Yes □ No
Pharmacy Name:______________________________________ Phone number:_________________________________
Pharmacy Address:__________________________________________________________________________________
2
FAMILY HISTORY:
Place of Birth:______________________________________ Language:_______________________________________
Race:______________________ Ethnicity:_________________________ Religion (optional):______________________
Do you live with your spouse? □ Yes □ No □ Not applicable
Do you have children? □ Yes □ No
If yes, please list:
CHILDREN: AGE HEALTH
______________________________ _______________ _____________________________________________
______________________________ _______________ _____________________________________________
______________________________ _______________ _____________________________________________
______________________________ _______________ _____________________________________________
Do any blood relatives have the following major health problems? If yes, who?
□ Asthma_________________________ □ Diabetes______________________ □ Hypertension__________________
□ Blood vessel disease_______________ □ Heart disease__________________ □ Psychological disorder___________
□ Cancer: Type:____________________________________ □ Other:_________________________________________
Are there any hereditary diseases in your family that you are aware of? □ Yes □ No
If yes, please list:____________________________________________________________________________________
SOCIAL HISTORY:
Marital Status: □ Married □ Separated □ Divorced □ Single □ Widowed
Tobacco Use: □ None □ Current Smoker: _____ pack(s) per day □ Chewing Tobacco □ Cigars
□ Previous Smoker: when did you quit?______________________
Alcohol Use: □ None □ Occasional / Social □ Daily
Occupation:_________________________________ Employer:___________________________________________
Length of Employment:___________________ Current Work Status: □ Regular Work □ Light Duty □ Off Work
Are you pregnant? □ Yes □ No Is it possible that you could be pregnant?___________________
Height:_______________ Weight:_________________ What is the most you have ever weighed?__________________
3
REVIEW OF SYSTEMS: (please check yes or no if you have had these in the last 6 months)
Y N Y N Y N
Constitutional: Recurrent fevers Fatigue Weight Loss / Gain
Skin: Rash Ulceration Excessive Dryness
Hematologic: Bruising Easy bleeding Swollen Glands
Endocrine: Tremors Hair Loss Generalized Weakness
Eyes: Blurry Dry Eyes Excess Tearing
ENT: Ringing Ears Bloody noses Trouble Swallowing
Cardio: Chest Pain Racing Heart Leg Swelling
Respiratory: Coughing Congestion Shortness of Breath
GI: Tarry Stools Bloody stools Abdominal Pain
Urinary: Frequency Blood in Urine Burning with Urination
Allergic/Immunologic: Asthma Hives Hay Fever
Musculoskeletal: Muscle Pain Joint Pain Joint Swelling
Neurological: Dizziness Facial pain Headaches
Psychiatric: Depression Anxiety Mood Swings
PAIN ASSESSMENT:
What kind of pain do you have: □ Sharp □ Aching □ Dull □ Throbbing □ Other:_______________________
Is the pain always there, or does it come and go?__________________________________________________________
Do you have weakness in your arms / legs? □ Yes □ No If yes, when did it start?____________________________
Do you have numbness or tingling in your arms / legs? □ Yes □ No If yes, when did it start?__________________
Have you had trouble controlling your bowels /bladder? □ Yes □ No If yes, when did it start?_________________
What makes the pain better / worse?
Walking: □ Better □ Worse □ No difference
Standing: □ Better □ Worse □ No difference
Sitting: □ Better □ Worse □ No difference
Lying down: □ Better □ Worse □ No difference
Bending: □ Better □ Worse □ No difference
Driving: □ Better □ Worse □ No difference
Coughing/ Sneezing: □ Better □ Worse □ No difference
How long can you sit with no/minimal pain:_______________________________________________________________
How long can you stand with no/minimal pain:____________________________________________________________
How long can you walk with no/minimal pain:_____________________________________________________________
4
PLEASE OUTLINE THE AREAS ON YOUR BODY WHERE YOU FEEL YOUR SYMPTOMS:
PLEASE CIRCLE THE NUMBER BELOW THAT DESCRIBES YOUR CURRENT PAIN:
NO PAIN 0 1 2 3 4 5 6 7 8 9 10 THE WORST PAIN YOU HAVE EVER HAD
Thank you for completing this form. Please bring it with you to your appointment.
5
