<</<</<<<< <</<</<<<< < << <<< * * *1* *TCO26* ! No Surgery or Treatment Scheduled Yet
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1 Cervical Myelopathy Pre-Treatment Form - Twin Cities Orthopedics STICKER FIELD If there is not any sticker available please write the required data below: Patient First Name: Patient Last Name: Medical Record Number: Date of Birth: Today's Date (MM/DD/YYYY) <</<</<<<< What s patient s height? < << Feet Inches What s patient s weight? <<< Pounds * * Planned Date of Treatment (MM/DD/YYYY) <</<</<<<<! No Surgery or Treatment Scheduled Yet (Please provide your address below for easy follow up and progress feedback) Please select your surgeon from the list below: Eric Deal, MD Jeffrey C Dick, MD David C Holte, MD John E Sherman, MD Michael D Smith, MD Race/Ethnicity (optional question): Please select one White Black or African-American Hispanic or Latino Asian American Indian and Alaska Native Native Hawaiian and Other Pacific Islander Other *1* Page 1 of 10
2 Patient Demographics Information Education Level: Please select the highest level of education you have received No schooling completed Less than 12th grade 12th grade, NO DIPLOMA High school DIPLOMA or the equivalent (for example: GED) Some college credit, but less than 1 year Associate degree (for example: AA, AS) Bachelor s degree (for example: BA, AB, BS) Master s degree (for example: MA, MS, MEng, MEd, MSW, MBA) Professional degree (for example: MD, DDS, DVM, LLB, JD) Doctorate degree (for example: PhD, EdD) Do you currently smoke cigarettes or use any other tobacco products? (Mark one response.) Yes No, I quit smoking or using any other tobacco products less than 6 months ago. No, I quit smoking or using any other tobacco products more than 6 months ago. No, I have never smoked or used any other tobacco products. (If select this choice; GO TO NEXT PAGE) How many years have you been smoking/using or did you smoke/use cigarettes or any other tobacco products? << Years On average, how many packs of cigarettes/tobacco products do you or did you smoke each day? ¼ pack per day or less (5 cigarettes or less) ½ pack per day 1 pack per day 1 ½ packs per day 2 packs or more per day *2* Page 2 of 10
3 Surgery History & Comorbidities Have you ever had any neck related spine surgery previously? No. I have never had neck related spine surgery previously I had 1 surgery I had 2 surgeries I had 3 or more surgeries Comorbidities: YES NO Do you have heart disease? If you have heart disease, does it limit your activities? Do you have lung disease? If you have lung disease, does it limit your activities? Do you have diabetes? Do you have fibromyalgia? Please continue to the next page *3* Page 3 of 10
4 EQ-5D-5L Under each heading, please select ONE choice that best describes your health TODAY. Mobility (Please mark one response) I have no problems walking I have slight problems walking I have moderate problems walking I have severe problems walking I am unable to walk *EQ-5D-5L* Self-Care (Please mark one response) I have no problems washing or dressing myself I have slight problems washing or dressing myself I have moderate problems washing or dressing myself I have severe problems washing or dressing myself I am unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) (Please mark one response) I have no problems doing my usual activities I have slight problems doing my usual activities I have moderate problems doing my usual activities I have severe problems doing my usual activities I am unable to do my usual activities Pain/Discomfort I have no pain or discomfort I have slight pain or discomfort I have moderate pain or discomfort I have severe pain or discomfort I have extreme pain or discomfort Anxiety/Depression (Please mark one response) (Please mark one response) I am not anxious or depressed I am slightly anxious or depressed I am moderately anxious or depressed I am severely anxious or depressed I am extremely anxious or depressed *4* Page 4 of 10
5 EQ-5D-5L (continues) We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to means the best health you can imagine. 0 means the worst health you can imagine. Select a number on the scale to indicate how your health is TODAY. Now, please write the number you selected on the scale in the box ABOVE. The best health you can imagine Your Health Today (0-100) <<< Please enter your health state score above *5* USA (English) 2009 EuroQol Group. EQ-5D is a trade mark of the EuroQol Group 0 The worst health you can imagine Page 5 of 10
6 Modified Japanese Orthopaedic Association (mjoa) Score 1. Motor dysfunction score of the upper extremities (Please mark one response) Inability to move hands Inability to eat with a spoon but able to move hands Inability to button shirt but able to eat with a spoon Able to button shirt with great difficulty Able to button shirt with slight difficulty No dysfunction *MJOA* 2. Motor dysfunction score of the lower extremities (Please mark one response) Complete loss of motor and sensory function Sensory preservation without ability to move legs Able to move legs but unable to walk Able to walk on flat floor with a walking aid (i.e., cane or crutch) Able to walk up and/or down stairs with hand rail Moderate to significant lack of stability but able to walk up and/or down stairs Mild lack of stability but walk unaided with smooth reciprocation (gait) No dysfunction 3. Sensation (Please mark one response) Complete loss of hand sensation Severe sensory loss or pain Mild sensory loss No sensory loss 4. Sphincter (Urination) dysfunction (Please mark one response) Inability to urinate voluntarily Marked difficulty with micturition (urination) Mild to moderate difficulty with micturition (urination) Normal micturition (urination) Benzel EC, Lancon J, Kesterson L, Hadden T: Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy. J Spinal Disord 4(3): , 1991 *6* Page 6 of 10
7 NECK DISABILITY INDEX This questionnaire is designed to give us information about how your NECK (or ARM) trouble affects your ability to manage your DAILY LIFE. Please answer every section and mark only the ONE CHOICE that applies to you. We realize that you may consider that two of the statements APPLY to you, but please just mark the CHOICE that most closely describes your problem. 1. Pain intensity (Please mark one response) I have no neck pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment. The pain is very severe at the moment. The pain is the worst imaginable at the moment. 2. Personal care (Please mark one response) I can look after myself normally without causing extra neck pain. I can look after myself normally, but it causes extra neck pain. It is painful to take care of myself, and I am slow and careful. I need some help but manage most of my personal care. I need help every day in most aspects of self -care. I do not get dressed. I wash with difficulty and stay in bed. *NDI* 3. Lifting! No Lifting is Allowed (Please mark one response) I can lift heavy weights without causing extra neck pain. I can lift heavy weights, but it gives me extra neck pain. Neck pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie. on a table. Neck pain prevents me from lifting heavy weights, but I can manage light weights if they are conveniently positioned. I can lift only very light weights. I cannot lift or carry anything at all. 4. Reading (Please mark one response) I can read as much as I want with no neck pain. I can read as much as I want with slight neck pain. I can read as much as I want with moderate neck pain. I can't read as much as I want because of moderate neck pain. I can't read as much as I want because of severe neck pain. I can't read at all. *7* Page 7 of 10
8 NECK DISABILITY INDEX (continues) 5. Headaches (Please mark one response) I have no headaches at all. I have slight headaches that come infrequently. I have moderate headaches that come infrequently. I have moderate headaches that come frequently. I have severe headaches that come frequently. I have headaches almost all the time. 6. Concentration (Please mark one response) I can concentrate fully without difficulty. I can concentrate fully with slight difficulty. I have a fair degree of difficulty concentrating. I have a lot of difficulty concentrating. I have a great deal of difficulty concentrating. I can't concentrate at all. 7. Work (Please mark one response) I can do as much work as I want. I can only do my usual work, but no more. I can do most of my usual work, but no more. I can't do my usual work. I can hardly do any work at all. I can't do any work at all. 8. Driving (Please mark one response) I can drive my car without neck pain. I can drive my car with only slight neck pain. I can drive as long as I want with moderate neck pain. I can't drive as long as I want because of moderate neck pain. I can hardly drive at all because of severe neck pain. I can't drive my car at all because of neck pain. *8* Page 8 of 10
9 NECK DISABILITY INDEX (continues) 9. Sleeping (Please mark one response) I have no trouble sleeping. My sleep is slightly disturbed for less than 1 hour. My sleep is mildly disturbed for up to 1-2 hours. My sleep is moderately disturbed for up to 2-3 hours. My sleep is greatly disturbed for up to 3-5 hours. My sleep is completely disturbed for up to 5-7 hours. 10. Recreation (Please mark one response) I am able to engage in all my recreational activities with no neck pain at all. I am able to engage in all my recreational activities with some neck pain. I am able to engage in most, but not all of my recreational activities because of pain in my neck. I am able to engage in only a few of my recreational activities because of neck pain. I can hardly do recreational activities due to neck pain. I can't do any recreational activities due to neck pain. COPYRIGHT: VERNON, H & HAGINO C, 1991 Please continue to the next and last questionnaire *9* Page 9 of 10
10 VISUAL ANALOG PAIN SCALE NECK PAIN Indicate the severity of your pain today by FILLING in any one circle that most applies to you. NECK PAIN: 0 No Pain RIGHT ARM PAIN: 10 Worst Possible Pain 0 No Pain LEFT ARM PAIN: 10 Worst Possible Pain 0 No Pain Neck Pain Questionnaire *VASNECKPAIN* 10 Worst Possible Pain *10* Thank you for completing the questionnaire Twin Cities Orthopedics Page 10 of 10
Cornerstone Health, 500 Davis Street, Suite #109, Evanston IL 60201
Patient's Name Number Date NECK DISABILITY INDEX This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage in everyday life. Please
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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Appendix A. DePaul Symptom Questionnaire. Please answer the following questions.
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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
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
Brewster Chiropractic Michael B. Singleton DC, MS, CNS, CSCS
Michael B. Singleton DC, MS, CNS, CSCS How did you hear about this office? Today s Date / / Signature of Patient Patient Title: (check one) Mr. Mrs. Ms. Miss Dr. Prof. Rev. First Name Preferred to be called
Do not write in this box. Name: Appointment: Date: Appointment Time: Primary Care Provider: Phone: Fax: Referring Physician: Address:
3901 Rainbow Boulevard Do not write in this box Appointment: Date: Appointment Time: Birth date: Age: Gender: Male Female Primary Care Provider: Phone: Fax: Referring Physician: Address: Phone: Fax: CHIEF
Personal Information. Full Name: Address: Primary Phone: Yes No Provider Yes No. Alternate Phone: Yes No Provider Yes No
OFFICE USE ONLY: Date of Intake: ID#: Staff mbr: Personal Information Full Name: Address: _ Last First M.I. Street Address Apartment/Unit # City State Zip Code County Date of Birth: Age: Mobile phone?
ABOUT YOUR KNEE ARTHROSCOPY...
Steven Struhl M.D. 57 West 57th Street Suite 1406 New York, NY 10019 212-207-1990 212-207-4656 (fax) ABOUT YOUR KNEE ARTHROSCOPY... General Overview Your doctor has recommended a knee arthroscopy to treat
Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)
Patient s Name: Date: What is the reason for your visit today? Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone #
ANNUAL FOLLOW-UP QUESTIONNAIRE
SLEEP HEART HEALTH STUDY - TUCSON ANNUAL FOLLOW-UP QUESTIONNAIRE - 2004 Dear Sleep Heart Health Study participant: Today s Date: / / Month Day Year Please take the time to complete and return this short
Allina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History
Welcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
Patient Demographics
M.D. INFO INSURANCE INFO PATIENT INFORMATION Patient's Name (Last, First, Middle Initial): Patient Demographics Patient's Address: City: Phone #: Home: Cell: Work: State: Zip Code: Patient Date of Birth
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Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit)
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit) Last name: First Name: Title: Mr. Mrs. Dr. Appt Date: Refer by: (Please provide name
List anything that caused/contributed to your problem(s) Is this new or Have you ever had these issues before? Yes No if yes, please explain
Name (Please Print)_ Date / / COMPLETE THESE DIAGRAMS Please list your areas of pain and then rate your pain. MARKING AREAS OF PAIN Zero=No Pain 0 1 2 3 4 5 6 7 8 9 10 10 =Unbearable 1. Rate 0-10 Onset
Child s Name Birth Date / / Age. Mother's Name. Father's Name. Phone: Home Cell. Address. Address Number & Street City State Zip
Welcome! Thank you for choosing our practice for your health needs. Your first visit to our center is an opportunity for us to learn all about you. If you have any questions or concerns, do not hesitate
Spine and Sports Intervention Center NW 89 th Blvd, Gainesville, FL (352)
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Neuropathic pain (pain due to nerve damage)
Neuropathic pain (pain due to nerve damage) Clinical Guideline Pain can be nociceptive, neuropathic or mixed. The neuropathic component of pain generally responds poorly to conventional analgesics. Consider
Adult New Patient Intake. Your Health Summary
Adult New Patient Intake Name Age Birth Date / / Soc. Sec. # - - Home Phone Cell Phone Address: City: State: Zip: Occupation: Email Marital Status: M W D S Spouse s Name: Children # and Ages: Whom may