Liza Maniquis-Smigel, MD

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Online Forms For Your Visit

New Patient Questionnaire

LIZA MANIQUIS-SMIGEL, M.D., LLC
Physical Medicine & Rehabilitation
Spine, Sports, & Electrodiagnostic Medicine Prolotherapy
136-A Ululani Street, Hilo, HI 96720
Phone: (808) 933-3444 Fax: 933-3433

NEW PATIENT QUESTIONNAIRE

Name * Age * Height * Weight * Occupation * 1. What Is Your Reason For Your Visit? *

2. On The Following Diagram Below, Please Write Down The Area Where Your Pain/Problem Occurs:

body

Front Of Body

Right Top Left Top Right Bottom Left Bottom Other (please explain)

Back Of Body

Right Top Left Top Right Bottom Left Bottom Other (please explain)

New Patient Questionnaire Second Page

3. When did you first notice the problem beginning (month/day/year)? 4. What Did You Believe Cause The Problem? Was There An Incidence Of Trauma Or Accident? 5.How Much Time Each Day Do You Experience Pain? (Select One) 6.Which Term Best Describe The Pain? You Can Select More Than One. Other (please explain) 7.What Helps You With The Pain (Relieving Factors)? 8.What Factors Aggravate Or Make The Pain Worse? 9.Did You Lose Any Strength & Sensation? If So, Please Describe: 10.Please List All Doctor's You Have Seen For This Problem: 11. Please List All The Diagnostic Tests You Have Hd For This Problem: 12. Have You Had Operations Or Procedures For This Problem? If So, Please List All The Operations You Have Undergone and Their Dates

New Patient Questionnaire Third Page

13. Have You Had Physcial Therapy For This Problem? If So, Please List Where, When And Physical Modalities Used 14. Are You Involved In Physical Activities? If So, Which Ones: Walking/Hiking Aeorbic Dancing Jogging/Running Rowing/Canoeing Tennis/Racket Sports Weight Lifting Swimming/Surfing Bicycling Stretching Other 15. List The Activities With Which Your Problem Has Interfered (Including Daily Activities, Social And Recreational Activities 16. What Are Your Goal For Being Here Today? 17. Past Medical History Diabetes High Blood Pressure Stroke Arthritis Asthma/TB TB Stomach Problems Swimming/Surfing Cancer Psychiatric Thyroid Disease Female Problems Heart None 18. Past Surgical History 19. List All Medications 20. Allergies

21. Family History

Father: CVA or Stroke Hypertension Diabetes Cancer Arthritis Other Mother: CVA or Stroke Hypertension Diabetes Cancer Arthritis Other Brothers: CVA or Stroke Hypertension Diabetes Cancer Arthritis Other Sisters: CVA or Stroke Hypertension Diabetes Cancer Arthritis Other

22. Social History

Where Do You Live Who Do You Live With? Number Of Children & Their Ages: Do You Smoke Do You Drink?

23. Review Of Systems:

How Do You View Your Current Health? Excellent Good Fair Poor Current Problems Include: Hand Arm Shoulder Spine Neck Hip Thigh Leg Feet Ankle Back Skin Headaches Weight Sleep Easy Fatigability Diarrhea/Constipation Depression Heart Palpitations Dizzness Breathing Urinary Sexual Anxiety

48. Have You Retained Services Of An Attorney? Yes No Name:

Thank you for completing this questionnaire. Your answers will be most useful in helping us understand you and your problem. If there is anything else you think we should know at this time, please feel free to use the space below. Thank you.

Comment Digital Signature (Your Name): * Date

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