1A – F5 – Reason for Visit

Reason for Visit

First Name

Last Name

DOB

Phone

What are you seeking help with?

Is there a secondary problem area?

Does the Pain Radiate?

No Right Left Both

If so, Where to?

Does the Pain Radiate?

No Right Left Both

If so, Where to?

Prior Imaging

We want to maximize your time with Dr. Rupert. Exceptional, targeted care requires a real-time review of your diagnostic imaging. To ensure we can move forward with your treatment plan, your scans must be accessible BEFORE (best) or at the time of your visit; otherwise, we may need to reschedule your appointment.

Please provide any physical imaging discs immediately upon arrival so our team can instantly sync them to your digital chart.

Imaging Studies

Have you had SURGERY or INJECTIONS for this?

Yes No

Please list

What have you been told the problem is? By whom?

What do you think the problem is?

What treatments or solutions have you been offered?

What treatment options are appealing to you? Anything specific?

What is an acceptable outcome?

Are there any specific quesitons you would like Dr. R to address during your visit?

Visit Preparation

Please CONFIRM we have any old imaging or that you have a physical disc.

Wear loose clothing / gym clothes for your examination of shoulder, hip, knee.

Cheif Complaint History

How long have you been seeking care?

Was there and inciting event?

(Approximately) When did the problem start?

How many providers or specialists have you worked with?

Pain Frequency and Severity

Most of the Time

Frequently

Intermittently

Have you gone to the ER for this?

No Yes

Number of Times

Over wwhat time frame?

List positions or physical activities that ALLEVIATE the symptoms?

List positions or physical activities that WORSEN or provoke the symptoms?

What word(s) describe the problem

Burning, Numbing, Tingling Deep, Dull, Aching Jolts/Stabbing Muscular Cramping

For JOINT pain - Do you have the following?

Swelling or Effusion / Fluid Decreased Range of Motion Abnormal Sounds / Grinding

For NERVE pain - Do you have the following?

Discoloration Regional Temperature Changes Nail or Hair Growth Changes

Have you tried the following?

NSAIDs or Tylenol > 3 weeks PT / Home Exercise > 6 weeks Activity Modification > 6 weeks