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Take Free Consultation

Welcome to JIP. To make your visit as pleasant as possible, we request all our patients to provide certain information about the health problems. This will help us in providing quality health care and a proper follow up.

Personal Information
Patient's Name* : Dr.'s Name* :
Age : E-Mail* :
Sex : Date :
Mobile* : Landline :

Medical Information
1.How did your pain start
2.When did start

3.Where is your pain (Please Enter the marking shown by the cursor in the above figure to make the doctor know where
the pain is, make sure you enter one value in the text box provided which is figured above)





4.Severity of pain (Rate your pain from 0 to 10 by circling the numbers)

   No pain       Excrutating pain  
Pain at it's worst


Pain at it's Best 

Usual pain level

5.How frequently you are troubled by pain? (Mark one of them)

Occasionally < 30% Intermittent 30 - 60% Nearly constant 60- 95% Constant 95 - 100%

6.What is the type of pain?(check all those which apply)

Burning Sharp Shooting Aching Throbbing Tingling


7.What factors increase pain?(check all those which apply)

Sitting Standing Walking Lying Coughing Sneezing Bending


8. What factors decrease pain?(check all those which apply)

Sitting Standing Ice Heat


9.Associated problems?(check all those which apply)

Numbness Headache
Weakness Dizziness
Tingling (pins & needles) Vomiting
Muscle spasms Urinary disturbances
Sleep disturbances Constipation / Diarrhea

10. Medical history (mark if you have that problem)

Heart problems - chest pain/swelling of feet Lung problems - breathlessness/cough High blood pressure
Diabetes Asthma  Kidney disease
Liver disease Arthritis Cancer
Paralysis  Seizures/fits/epilepsy  Thyroid
Acidity/heart burn/regurgitation    Depression Recent weight loss/gain
Recent fever with chills & rigornbsp  Vision/hearing problems Allergy
Excessive bleeding from injuries Hot & cold feeling in hands, feet, face  

Previous Surgeries/injuries

Family Medical history

Menstrual history (if applicable)

a) Duration of periods

b) Regular/irregular cycles
c) Excessive flow/scanty flow

d) Pain during periods

Married life (if applicable)

a) How many years of marriage?

b) Children / ages Number of Children Ages Ages

c) Family life

Personal history
a) Do you smoke If Yes How many Packs per day
b) Do you take alcohol If Yes what is the frequency
c) Any drug

Occupational history

a) Occupation

b) Place of employment
c) Are you employed now

d) Describe If yes did you Stop working because of the pain  
1) Are you receiving compensation or disability payment

2) Do you have any application for compensation or disability

3) Are you currently involved in litigation or planning on taking legal action becauseof pain/injury

List any previous treatment you had for your pain (physical therapy, occupational therapy, TENS, acupuncture, psychologist, .....)

Any previous injections or nerve block for pain relief
Location on body Date Length of relief
  less than a day few weeks
few days month or more
less than a day few weeks
few days month or more

Pain medications being taken currently
Medication (Name) Dose Frequency Duration of relief Date started

Other medication ( Non pain medication )
Medication (Name) Dose Frequency Duration of relief Date started

We know it was a laborious process to go through all the questions. But all these information are essential for a complete workup. Our medical team will go through these details. Depending on their assessment, they will plan the subsequent steps of treatment. There might be a need for personal visit to the doctor at JIP. Quite often the treatment will be started only after examining the patient thoroughly. We will get back to you at the earliest with suggestions for your problems. In between if you have any problem, please call us on ......

We once again thank you for all the information provided