Fakhoury Medical & Chiropractic Center
Ocala, Fl
Car Accident or Pain?
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+1 (352) 351-3413
head2toecare@gmail.com
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Ocala Car Accident Doctor
CHIROPRACTIC CARE
MANUAL THERAPY
PHYSIOTHERAPY
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INTERVENTIONAL MEDICINE
EMG STUDIES
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SPORTS INJURY
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TREATMENT OF NECK PAIN
TREATMENT OF MIDDLE AND LOWER BACK PAIN
TREATMENT OF RIB PAIN
TREATMENT OF PAIN IN THE JOINTS
LASER THERAPY
CAR ACCIDENT INJURY TREATMENT
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OCALA
FL
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Do you or have ever had any heart problems in your past or currently?
Yes
No
Have you ever in the past or do you currently take any blood thinners? (Asprin, Coumadin, Plavix)
Yes
No
Are you currently taking any anti-inflammatories? (Motrin, Advil, Naproxen, Mobic, etc)
Yes
No
Have you ever in the past or do you currently take any drugs to maintain normal heart rhythm?
Yes
No
If you have high blood pressure, has it ever been over 180/100?
Yes
No
Have you ever had a seizure?
Yes
No
Do you have allergies to iodine?
Yes
No
Have you had any IV (intravenous) dye injections?
Yes
No
Have you had any recent infections? (past three months)
Yes
No
Have you ever had an infection with MRSA (Methicillin-Resistant Staphylococcus Aureus)?
Yes
No
Do you have a history of retinal detachment or glaucoma?
Yes
No
Do you have diabetes? If so, are you insulin dependent?
Yes
No
Females Only: Is there any chance you could be pregnant?
Yes
No
Females Only: Are you currently breast feeding?
Yes
No
What is/are your main problems?
When did your problems starts? (weeks, months, years, specific dates)
What caused your symptoms? (fall, motor vehicle accident, etc)
How would you describe your pain? Choose all that apply
Achy
Dull
Sharp
Burning
Throbbing
Numbness
Which side hurts the most?
Achy
Right
Left
Both sides
The middle
Have you had any muscle spasms or tightness? If so, where?
Have you had any numbness and if so, where?
Does the pain tend to travel anywhere? (down the leg, arm, etc)
Over the past few weeks, is your pain
Improving
Worsening
Not getting any better
The same
Is the pain constant or intermittent (off and on)
Yes
No
What worsens the pain?
Standing
Sitting
Lying Down
Walking
Twisting
Driving
Reaching
Heat
Cold
Coughing
Sneezing
Leaning Forward
Other
What reduces the pain?
Standing
Sitting
Lying Down
Walking
Twisting
Driving
Reaching
Heat
Cold
Coughing
Sneezing
Leaning Forward
Other
How would you rate your pain level on a typical day from 1 to 10.
0 = No pain
1,2,3 = Minor aches
4,5,6 = Moderate
7,8,9 = Intense
10 = Emergency
What can you no longer do because of pain? (Goals of treatment)
Has this affected your sleep? Yes or No. If so, how many hours do you sleep.
Please list prior pain medicine
Have you ever had any of the following studies?
EMG (nerve study)
MRI
CT Scan
X-rays
Bone Scan
Have you ever had any of the following procedures or therapies?
Chiropractic
Physical Therapy
Epidural
Join Injections
Do you have a primary care physician? Please list name and location
Do you have a pharmacy you use? If so which pharmacy and where is it located?
What is your past/current medical history?
Diabetes
Cancer
Liver Disease
Depressions
Heart disease
Ulcers/GI disease
Stroke
Kidney disease
Anxiety
High blood pressure
Asthma/Emphysema
Bipolar Disorder
Other
What is your past surgical history?
Diabetes
Cancer
Liver Disease
Depressions
Heart disease
Ulcers/GI disease
Stroke
Kidney disease
Appendix/Gall bladder removal
Tonsillectomy
Hernia repair
C-Section
Hysterectomy
Other
Are you taking any prescription medications? If yes please list.
Are you taking any over the counter medications? If yes, please list
Are you allergic to any medications? Please provide drug/reaction
Are you
Married
Single
Divorced
Widowed
Do you have any children?
Yes
No
Alcohol use
None
Social
Moderate
Daily (more than 2)
Do you smoke
Yes
No
How many packs a day
Have you ever taken/used illicit drugs?
Yes
No
What is your occupation? Full or Part Time
Are you working full or light duty?
Full
Light Duty
Not working
Have you tried to return to work?
Yes
No
Is there a lawyer involved?
Yes
No
Have you applied or intend to apply for social security?
Yes
No
Do you have any hobbies or activities that require a moderate level or physical activity?
Family History
Genetic Diseases
Stroke
Diabetes
Heart Disease
Muscle Disease
Neurological Disease
Alcoholism or Illegal Substance Abuse
Other
Other
Have you had any of the following symptoms i nthe past month?
Weight Loss
Ringing in the ears
Recent vision changes
Cough
Nausea or Vomiting
Change in Urinary Habits
Easy bruising
Recent memory loss
Difficulty holding urine/bowel movements
Fever/Chills
Recent Hearing Loss
Chest Pain
Wheezing
Diarrhea/Constipation
Blood in Urine
Discoloration
Depression
Night sweats
Dizziness
Shortness of Breath
Abdominal Pain
Bloody or black stools
Skin Rash
New onset Seizures
Hot or Col Temp Intolerance
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