NON-INJURY QUESTIONNAIRE
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1 Patient Name: Appointment Date: Appointment with: Dr. Jeffrey A. Kozak NON-INJURY QUESTIONNAIRE Why did you make an appointment to see the doctor? Evaluation Surgical Opinion Reassurance Other Specify: What part of your spine hurts? Cervical (neck) Thoracic (upper back) Thoracolumbar (mid back region) Lumbar (low back) Sacroiliac (tailbone) Please give a BRIEF history of your symptoms: What was the date of your current onset of symptoms? Is this the first time you have had these symptoms? If no, please specify date your symptoms first began Yes No Date: Have you ever had surgery on your NECK or BACK? Yes No If yes, please complete the following: 1.) Type of surgery: Date: Surgeon: Did it make your pain better worse no change 2.) Type of surgery: Date: Surgeon: Did it make your pain better worse no change
2 NON-INJURY QUESTIONNAIRE Page 2 NECK TO ARM PAIN RATIO: (Fill out only if you have neck pain) Yes No Is the neck pain greater than arm pain? Is arm pain greater than neck pain? Please circle one of the ratios listed below which best describes the amount of pain you feel in your neck as compared to your arm. Neck pain compared to arm pain: 100% neck pain compared to 0% arm pain 90% neck pain compared to 10% arm pain 80% neck pain compared to 20% arm pain 70% neck pain compared to 30% arm pain 60% neck pain compared to 40% arm pain 50% neck pain compared to 50% arm pain 40% neck pain compared to 60% arm pain 30% neck pain compared to 70% arm pain 20% neck pain compared to 80% arm pain 10% neck pain compared to 90% arm pain 0% neck pain compared to 100% arm pain BACK TO LEG PAIN RATIO: (Fill out only if you have low back pain) Yes No Is back pain greater than leg pain? Is leg pain greater than back pain? Please circle one of the ratios listed below which best describes the amount of pain you feel in your back as compared to your leg. Back pain compared to leg pain: 100% back pain compared to 0% leg pain 90% back pain compared to 10% leg pain 80% back pain compared to 20% leg pain 70% back pain compared to 30% leg pain 60% back pain compared to 40% leg pain 50% back pain compared to 50% leg pain 40% back pain compared to 60% leg pain 30% back pain compared to 70% leg pain 20% back pain compared to 80% leg pain 10% back pain compared to 90% leg pain 0% back pain compared to 100% leg pain
3 NON-INJURY QUESTIONNAIRE Page 3 Please list any medications you are taking for your current problem. Medication Prescribed By Date Initiated Results Which treatment have you received for your current injury? Please specify length of time & results. Length of time Results Acupressure Acupuncture Biofeedback Brace Chiropractor Hypnosis Occupational therapy Physical therapy Other Specify: Please list any x-rays/tests performed for your current injury. X-ray/Test Area of Body Date Facility/Hospital Bonescan CT Scan Discography Doppler Studies EMG/NCV Facet Block Inj. Gallium Scan Indium Scan MRI Myelogram Nerve Root Inj. Plain X-rays Other
4 NON-INJURY QUESTIONNAIRE Page 4 With these activities, is your pain better, worse or unchanged? Better Worse Unchanged With cough or sneeze Sitting down at a table Sitting in an automobile Bending forward to brush teeth Walking a short distance Lying flat on back Lying flat on stomach Lying on side with knees bent Upon awakening in the morning Mid-morning Middle of the night PLEASE CHECK THE BEST ANSWER AS IT RELATES TO YOUR CURRENT FUNCTION PAIN INTENSITY 1. Tolerate pain without pain medication 2. Pain, but do not take pain killers 3. Pain killers give complete relief 4. Pain killers give moderate relief 5. Pain killers give very little relief 6. Pain killers have no effect on pain, therefore, do not use WALKING 1. Pain does not prevent me from walking any distance 2. Pain prevents me from walking more than 1 mile 3. Pain prevents me from walking more than ½ mile 4. Pain prevents me from walking more than ¼ mile 5. Can only walk using a cane or crutch 6. Restricted to bed and have to crawl to the toilet PERSONAL CARE 1. Look after myself normally without causing extra pain 2. Look after myself with some extra pain 3. Painful, but I do it slowly and carefully 4. Need some help but manage most of my personal care 5. Need help every day in most aspects of my care 6. Do not get dressed and stay in bed WORKING 1. Work 8 hours per day without pain 2. Work 8 hours, but it causes pain 3. Cannot work 8 hours, but can work 4 hours 4. Cannot work 4 hours without pain 5. Cannot work SOCIAL LIFE 1. Normal with no pain 2. Normal, but increases the pain 3. Limits my more energetic interests such as dancing 4. Limits my social life and I do not go out often 5. Has restricted my social life to my home 6. I have no social life because of my pain STANDING 1. Pain does not prevent me from standing 2. Cannot stand longer than 1 hour due to pain 3. Cannot stand longer than 30 minutes due to pain 4. Cannot stand longer than 10 minutes due to pain 5. Can only stand with assistance 6. Cannot stand at all SITTING 1. Can sit in any chair as long as I like 2. Can only sit in my favorite chair as long as I like 3. Cannot sit more than 1 hour 4. Cannot sit more than 30 minutes 5. Cannot sit more than 10 minutes 6. Cannot sit at all LIFTING 1. Can lift any weight without problem 2. Can lift, but it causes spinal pain 3. Cannot lift over 20lbs 4. Cannot lift over 10lbs 5. Cannot lift without pain SLEEPING 1. Pain does not prevent me from sleeping 2. Sleep only with medication 3. Sleep less than 6 hours with medication 4. Sleep less than 4 hours with medication 5. Sleep less than 2 hours with medication 6. Pain prevents me from sleeping at all TRAVELING 1. Can travel anywhere without extra pain 2. Can travel anywhere with some pain 3. Pain is bad but manage journey over 2 hours 4. Pain restricts journeys to less than 1 hour 5. Pain restricts journeys to under 30 minutes 6. Pain prevents any travel except to doctor/hospital
5
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Good. Poor [ ] [ ] Yes, at all [ A ] Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [ ] [ ]
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Mail: Omega Institute for Holistic Studies Attn: Registration Dept 150 Lake Drive Rhinebeck, NY Or scan and
Dear Omega Your Brain Without Pain participant, We are looking forward to teaching you methods that will enable you to stimulate your brain to grow new neurological pathways that create detours around
PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
Patient# WELCOME Today s Date / / Please fill out this form as completely as possible. Please print. PERSONAL INFORMATION Name What you prefer to be called Age Date of Birth / / Sex SS# E-Mail Home Address
Sciatica. 43 Thames Street, St Albans, Christchurch 8013 Phone: (03) Website: philip-bayliss.com
43 Thames Street, St Albans, Christchurch 8013 Phone: (03) 356 1353. Website: philip-bayliss.com Sciatica Nagging, burning pain radiating down the back of the leg, or dull throbbing pain in the buttocks
Dr. Edwards New Patient Paperwork Please fill out these forms completely
Dr. Edwards New Patient Paperwork Please fill out these forms completely Date of Appointment Complete the enclosed packet and bring it to the appointment along with all X Rays, MRI disc and reports. Please
New Patient Information and History Form
New Patient Information and History Form John K. Dorman, M.D., FACS Diplomate of The American Board of Neurological Surgery 400 Rosalind Redfern Grover Parkway Suite 200 Midland, TX 79701 432 687-2350
PRIMARY COMPLAINT: Date when symptom first appeared Did it begin: Gradual Sudden Progressive over time
PATIENT HISTORY 1 Date of Birth Age Social Security # Last First Middle Initial Address City ST Zip Phone (H) (W) (C) Email May we send you our online newsletter? Yes No Your Occupation Employer Spouse
Chima Ohaegbulam, MD Spine Surgery, Neurosurgery
Chima Ohaegbulam, MD Spine Surgery, Neurosurgery Converse 4 617 754 6025 125 Parker Hill Avenue FAX 617 754 6026 Boston, MA 02120 spineboston.com Dear You have been scheduled for an initial evaluation
PLEASE BRING COMPLETED PACKET TO APPOINTMENT ALONG WITH YOUR FILMS
PLEASE BRING COMPLETED PACKET TO APPOINTMENT ALONG WITH YOUR FILMS Advanced Spine Associates, P.A. NEW PATIENT MEDICAL HISTORY QUESTIONNAIRE Name Address City State Zip Age Date of Birth Sex M F Phone
2517 Lebanon Pike, Suite 101 Nashville, Tennessee
If you need any assistance completing this form, please ask any team member. Thank you! First Appointment Date First Name Last Name MI Name you preferred to be called Male Female Address City ST ZIP Social
SPINE PROGRAM NEW PATIENT FORM
Name: Date of Birth: Today s Date: Are you right or left handed? What are your goals for the visit? Who referred you to us? Primary Doctor Another Doctor Dr. Of what specialty? Someone else: PAIN 1. Tell