Medical Record Form New Castle Patient Name Date Have you RECENTLY noticed any of the following (check all that apply) Changes in your health Nausea/Vomiting Dizziness/light headaches Numbness or tingling Changes in bowel/bladder function Weight loss/gain Shortness of breath Headaches Changes in appetite Urinary tract infection Difficulty Swallowing Pain at night Balance issues/falls Fever/chills/sweats Chest pain Have you EVER been diagnosed with any of the following (check all that apply) Cancer Heart problems High blood pressure Circulation problems Lung problems Chemical dependency (i.e. alcoholism) Multiple sclerosis Chest pain/angina Rheumatoid arthritis Osteoarthritis Depression Asthma Hepatitis Thyroid problems Tuberculosis Osteoporosis Diabetes Stroke Blood clots Pacemaker inserted Epilepsy Kidney problems Liver problems Other Has anyone in your IMMEDIATE FAMILY ever been diagnosed with any of the following (check all that apply) Cancer Heart problems High blood pressure Diabetes Stroke Depression Tuberculosis Thyroid problems Blood clots Medications Allergies Do you smoke? Yes No Date your symptoms began (rough estimate) What do you think caused your symptoms What is your goal for therapy? I should not do physical activities that make my pain worse Agree Disagree Are your symptoms currently Getting better Getting worse Staying the same What treatment have you received for this problem so far When are your symptoms worst Morning Afternoon Evening After exercise When are your symptoms best Morning Afternoon Night After exercise Occupation Leisure activities Are you depressed? Yes No Is your depression related to your injury? Yes No If you are human, leave this field blank. Submit
