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40 Park Avenue, Suite 1
New York, NY 10016
Phone: 646-455-1564
Fax: 646-205-4041

Health History Questionnaire

All questions combined in this questionnaire are strictly confidential and will became part of your medical record.

Original Date:

Date Revised:

M F
Single Partnered Married Separated Divorced Widowed

PERSONAL HEALTH HISTORY

 
Foot Ankle Knee Other:
 
Right Left Both When did this start?:

Chief
Complaint:

 
Constant
Intermittent
With activity
Better
Worse
Unchanged
1 2 3 4 5 6 7 8 9 10

(0=Pain Free and 10=Worst Pain Ever)

No Yes If Yes
Swelling
Locking/catching
Achiness/dull pains
Stiffness
Grinding
Clicking/popping
Dislocation
Rest/pain
Numbness/tingling
Night Pain
Instability/giving way/buckling
Electric/Shooting/Sharp Pains
No
Yes. If so, describe
X-ray
MRI
PT
Orthotics
Shoewear change
Injections
Activity Modification
Ice or Heat
Rest
Blood work
Meds
CT Scan
Bone Scan
Surgery
ER Visit
Surgery
Other
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