ANANT KUMAR, M.D. New Patient Questionnaire Thoracic and Lumbar Spine
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1 ANANT KUMAR, M.D. New Patient Questionnaire Thoracic and Lumbar Spine Please answer all questions completely
2 Colorado Back and Spine Dr. Anant Kumar 2 Date: Patient Name: Referring doctor name and address: If you were not referred by a physician, how did you find our office? Primary care doctor name and address: 1. Your age: Years Gender: Male Female 2. Symptoms: BACK pain LEG pain Numbness Weakness Other 3. How long have you had your symptoms? 4. What caused your symptoms? Unknown Injury Other 5. Have your symptoms improved or worsened recently? Improved Worsened 6. When did and what caused your symptoms improve or worsen? What % of your symptoms is in the BACK and LEG? (please check one box) BACK 0%, LEG 100% BACK 10%, LEG 90% BACK 25%, LEG 75% BACK 50%, LEG 50% BACK 75%, LEG 25% BACK 90%, LEG 10% BACK 100%, LEG 0% What % of your symptoms is in each LEG? (please check one box) No LEG symptoms Right 0%, Left 100% Right 10%, Left 90% Right 25%, Left 75% Right 50%, Left 50% Right 75%, Left 25% Right 90%, Left 10% Right 100%, Left 0% Where in your LEG do you have PAIN or TINGLING? Right Left Buttock Buttock Thigh, back Thigh, back Thigh, front Thigh, front Foot Foot Where in your LEG do you have NUMBNESS Right Left Buttock Buttock Thigh Thigh Ankle Ankle Foot /toes Foot/toes Where in your LEG do you have WEAKNESS Right Left Buttock Buttock Thigh Thigh Ankle Ankle Foot Foot
3 Colorado Back and Spine Dr. Anant Kumar 3 MY BACK PAIN IS (circle number) No Pain Slight Mild Moderate Severe Excruciating Pain as bad as it could be MY LEG PAIN IS (circle number) No Pain Slight Mild Moderate Severe Excruciating Pain as bad as it could be Please mark the areas on the diagram where you are having symptoms and the location where the symptoms radiate. Please use the following symbols to indicate the type of symptoms and the location of the symptoms: Pain= Pins and Needles= Numbness= XXXXXXXXXXX
4 Colorado Back and Spine Dr. Anant Kumar 4 7. How does your pain travel: Stays in my BACK Starts in the BACK and goes down the LEG 8. The worst position for pain is: No pain Sitting Standing Walking 9. Bending forward? Increases the pain Decreases the pain No effect 10. Lying down? Increases the pain Decreases the pain No effect 11. How many minutes can you STAND without pain? How many minutes can you WALK without pain? Does coughing or sneezing increase your symptoms? Yes No 14. Do you have difficulty with bowel or bladder control? No Yes; since 15. Have you missed work because of your symptoms? No Yes; how much time 16. Previous treatments for my condition have included: (check any boxes that apply) Nothing (no medicines, therapy, manipulations, injections, or braces) Physical therapy: did it help relieve your symptoms? Chiropractic manipulation; did it help relieve your symptoms? Braces; did it help relieve your symptoms? Spine injections: How many injections have you had? For how long did the injections relieve your pain? Surgery How many surgeries have you had on your BACK? When was/were the surgery(ies) on your BACK? Did surgery relieve your symptoms? Other treatment: 17. Previous doctors seen for your spine problem: Doctor Specialty City Recommendations/Treatments 18. List pain medications and dose taken for your spine problem: Medication Dose
5 Colorado Back and Spine Dr. Anant Kumar 5 MEDICAL CONDITIONS THAT YOU HAVE OR HAD IN THE PAST: (check all that apply) apply Heart attack Diabetes Lung disease Liver trouble Heart failure Stroke HIV Hepatitis High blood pressure Seizures AIDS Thyroid trouble Osteoarthritis Mental illness Tuberculosis Bleeding disorders Rheumatoid arthritis Kidney stones Asthma Anemia Ankylosing spondylitis Kidney failure Blood clot in LEG Blood clot in lung Gout Stomach ulcers Alcoholism Drug use Osteoporosis Cancer (type) Serious injuries (explain) Other (explain) MEDICATIONS YOU TAKE (please list): ARE YOU ALLERGIC TO ANY MEDICINE? No known drug allergies Medication Reaction Are you allergic to latex? Yes No Have you had complications with anesthesia? Yes No PAST SURGICAL HISTORY Please list previous surgeries, surgeon and date. OPERATION SURGEON DATE FAMILY HISTORY: (check all that apply) apply Scoliosis Spine problems Arthritis Mental illness Alcoholism Heart trouble Stroke High blood pressure Diabetes Seizures Cancer Bleeding disorders Blood clots Other
6 Colorado Back and Spine Dr. Anant Kumar 6 SOCIAL HISTORY: (check all that apply) 1. Work status: Working: Full time Part time Retired Disabled Unemployed Occupation: 2. Marital status: Married Single Co-habitating Widowed Divorced 3. I live: Alone With: 4. Number of living children: 5. Tobacco and nicotine use: Never Cigar Chew Pipe Cigarettes packs per day for years. Quit When? after smoking packs per day for years 6. Alcohol intake: Never <2 drinks/month 1-2 drinks/week 1-2 drinks/day 7. Drug use: Never Currently In the past 8. If you have scoliosis how old were you when you started your menstrual cycle? 9. Because of my spine problem, I have filed or plan to file: A lawsuit A Worker s Compensation claim Neither REVIEW OF SYSTEMS: (check all that apply) Constitutional apply Recent weight change Poor appetite Hot or cold spells Fever or chills Eyes Cardiac Respiratory Gastrointestinal apply Change of vision Reading glasses apply Abnormal heartbeat Heart or chest pain Swollen ankles apply Shortness of breath Morning cough apply Frequent Constipation Frequent diarrhea Stomach pain Ulcers Nausea or vomiting Genitourinary apply Frequent urination Burning with urination Difficulty starting urination Neurologic apply Frequent headaches Blackouts Seizures Weakness Skin ENMT Heme/Lymph Psychiatric Patient Signature Numbness apply Frequent rash Acne apply Gum trouble Toothache Loss of hearing Cavities Missing teeth Dentures Ear pain/infection Nosebleeds Hoarseness Difficulty swallowing apply Anemia Blood clots Easily bruising Bleeding disorder apply Depression Schizophrenia Bipolar disorder Alcoholism Drug abuse Date Physician Signature Date
7 Colorado Back and Spine Dr. Anant Kumar 7 Physical Examination (FOR OFFICE USE ONLY Patients continue to the next page) 1. Constitutional: 2. Neurological a. Vital Signs: Height Weight Pulse Resp b. Appearance: Nutrition Habitus Deformity Grooming a. Orientation (PERSON/PLACE/TIME) Mood/ Affect (depression, anxiety, agitation) 3. SKIN (scars, ulcerations, etc; location); Neck Back BUE BLE 4. Adams forward bend: PT MT TL/L 5. Pain Range of Motion Cervical/Thoracolumbar Spine (Yes/No) 6. Pain palpation Cervical/Thoracolumbar Spine (Yes/No; Location) 7. GAIT: Tandem gait: (steady / unsteady); Able to Heel walk: (+ / - ); Able to Toe walk:(+ / - ) 8. Motor: Delt Bi Tri WE WF FF INT Psoas Quad DF EHL PF INV EVER R L 9. Sensation: (symmetric, deficits, region of deficit): 10. DTR: Biceps Triceps BR Knee Ankles Babinski Hoffman s Clonus Umbilicus R L 11. Cardiovascular: DP PT Vascular changes Swelling R L Lab/EMG Results: Exam type Date obtained Findings Diagnostic Imaging Exam type Date obtained Findings Straight LEG raise Femoral Stretch Test Pain hip ROM Pain knee ROM Pain Shoulder ROM Coordination SI pain Rhomberg Carpal/Cubital tunnel exam Assessment Recommendations: Prescription Drug (mod-mgmt) (high DxP) Surgery (high) Physical Therapy (low-mgmt) Injections
8 Colorado Back and Spine Dr. Anant Kumar 8 Modified Oswestry Low Back Pain Disability Questionnaire a This questionnaire has been designed to give your doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer every question by placing a mark in the one box that best describes your condition today. We realize you may feel that two of the statements may describe your condition, but please mark ONLY the box that most closely describes your current condition. a Modified by permission of The Chartered Society of Physiotherapy from Fairbanks JCT, Couper J, Davies JB, et al. The Oswestry Low Back Pain Disability Questionnaire. Physiotherapy 1980;66: Pain Intensity I can tolerate the pain I have without having to use pain medication The pain is bad, but I can manage without having to take pain medication Pain medication provides me with complete relief from pain Pain medication provides me with moderate relief from pain Pain medication provides me with little relief from pain Pain medication has no effect on my pain Personal Care (e.g., Washing, Dressing) I can take care of myself normally without causing increased pain I can take care of myself normally, but it increases my pain It is painful to take care of myself and I am slow and careful I need help, but I am able to 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 Lifting I can lift heavy weights without increased pain I can lift heavy weights but it gives increased pain Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (e.g., on a table) Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned I can lift only very light weights I cannot lift or carry anything at all Walking Pain does not prevent me from walking any distance Pain prevents me from walking more than 1 mile Pain prevents me from walking more than ½ mile Pain prevents me from walking more than ¼ mile I can only walk with crutches or a cane I am in bed most of the time and have to crawl to the toilet Sitting I can sit in any chair as long as I like I can only sit in my favorite chair as long as I like Pain prevents me from sitting for more than 1 hour Pain prevents me from sitting for more than ½ hour Pain prevents me from sitting for more than 10 minutes Pain prevents me from sitting at all Standing I can stand as long as I want without increased pain I can stand as long as I want, but it increases my pain Pain prevents me from standing more than 1 hour Pain prevents me from standing more than ½ hour Pain prevents me from standing more than 10 minutes Pain prevents me from standing at all Sleeping Pain does not prevent me from sleeping well I can sleep well only by using pain medication Even when I take pain medication, I sleep less than 6 hours Even when I take pain medication, I sleep less than 4 hours Even when I take pain medication, I sleep less than 2 hours Pain prevents me from sleeping at all Social Life My social life is normal and does not increase my pain My social life is normal, but it increases my level of pain Pain prevents me from participating in more energetic activities (e.g., sports, dancing) Pain prevents me from going out very often Pain has restricted my social life to my home I have hardly any social life because of my pain
9 Colorado Back and Spine Dr. Anant Kumar 9 Traveling I can travel anywhere without increased pain I can travel anywhere, but it increases my pain My pain restricts my travel over 2 hours My pain restricts my travel over 1 hour My pain restricts my travel to short necessary journeys under ½ hour My pain prevents all travel except for visits to the physician/therapist or hospital Employment/Homemaking My normal homemaking/job activities do not cause pain My normal homemaking/job activities increase my pain, but I can still perform all that is required of me I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (e.g., lifting, vacuuming) Pain prevents me from doing anything but light duties Pain prevents me from doing even light duties Pain prevents me from performing any job or homemaking chores Patient Signature Date
10 Colorado Back and Spine Dr. Anant Kumar 10 Zurich Claudication Questionnaire Please read: This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only the ONE box that applies to you. We realize you may consider that two of the statements in any one section related to you, but please just mark the box that most closely describes your problem. Symptom Severity Scale 1. The pain you have had on average including the pain in your back, buttocks and pain that goes down you legs: Very Severe Severe Moderate Mild 2. How often have you had back, buttock, or leg pain? Every minute of the day Everyday for most of the day Everyday, for at least a few minutes At least once a week Less than once a week 3. The pain in your back or buttocks? Very Severe Severe Moderate Mild 4. The pain in your legs or feet? Very Severe Severe Moderate Mild 5. Numbness or tingling in your legs or feet? Very Severe Severe Moderate Mild 6. Weakness in your legs or feet? Very Severe Severe Moderate Mild 7. Problems with your balance? Yes, often I feel my balance is off, or that I m not sure footed Yes, sometimes I feel my balance is off, or that I m not sure footed No, I have had no problems with balance Physical Function Scale 8. How far have you been able to walk? Less than 50 feet Over 50 feet, but less than 2 blocks Over 2 blocks, but less than 2 miles Over 2 miles 9. Have you taken walks outdoors or in malls? No Yes, but always with pain Yes, but sometimes with pain Yes, comfortably 10. Have you been shopping for groceries other items? No Yes, but always with pain Yes, but sometimes with pain Yes, comfortably 11. Have you walked around the different rooms in your house or apartment? No Yes, but always with pain Yes, but sometimes with pain Yes, comfortably
11 Colorado Back and Spine Dr. Anant Kumar Have you walked from your bedroom to the bathroom? No Yes, but always with pain Yes, but sometimes with pain Yes, comfortably Patient Signature Date
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HEALTH QUESTIONNAIRE
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Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?
Gregory H. Tchejeyan, M.D., Inc. Please fill out this form in its entirety. Please complete every line item, as it is necessitated by regulations from the government (Health Care Finance Administration
BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage
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RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:
Practice: Today s Date: Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E-mail newsletters, reminders, statements, etc. Address: City: State:
Eastern Shore MediCann Clinic, LLC
Eastern Shore MediCann Clinic, LLC New Patient Medical History and Intake Form Medical Marijuana Certification Name Date of Birth Social Security Number Gender: Male Female Address: Street: City: State
Name: Sex: Male Female. Date of Birth: Occupation: Is this an accident or work related injury?
Name: Sex: Male Female Date of Birth: Occupation: Is this a 2 nd opinion? Yes No Is this an accident or work related injury? Please list: Family MD: Referring MD: Address: Address: Phone: Phone: Fax: Fax:
BACK AND LEG PAIN ASSESSMENT (Prior Surgery)
ANSWER EVERY QUESTION! SPINE SURGERY LTD. (IMPORTANT PATIENT INFORMATION FORM) BACK AND LEG PAIN ASSESSMENT (Prior Surgery) 1. NAME: DATE TODAY: 2. AGE: SEX: 3. PRESENTLY EMPLOYED? NO YES, How long there?
Worker s Compensation Form
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Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
GENERAL INFORMATION HISTORY QUESTIONNAIRE Name: Today s Date: Age: Date of birth: Sex: M F SS#: Home Address: Cell Phone: Your doctor: Home Phone: Your Attorney (if any): If questions arise after today
I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
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Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
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Brett A. Taylor, MD 14825 N. Outer Forty Rd., Suite 200 Chesterfield, MO 63017 Phone: (314) 336-2555 www.toc-stl.com SPINE PATIENT QUESTIONNAIRE (Cervical & Lumbar Attachment) Please answer all questions
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
TOWN AND COUNTRY CROSSING ORTHO PEDICS
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COOK CHIROPRACTIC CLINIC 1715 S MAIN ST KANNAPOLIS NC FX:
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HD CLINIC MEDICAL HISTORY FORM
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Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone E-Mail Address
Questionnaire for Lipedema Patients
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NAME OF PATIENT: STREET ADDRESS: CITY: STATE: ZIP: SEX: Male Female AGE: BIRTHDATE: MARITAL STATUS: PATIENT EMPLOYED BY: BUSINESS ADDRESS:
DATE: HOME PHONE: NAME OF PATIENT: (Last name) (First name) (Middle) RESPONSIBLE PARTY (if a minor): STREET ADDRESS: CITY: STATE: ZIP: SEX: Male Female AGE: BIRTHDATE: MARITAL STATUS: PATIENT EMPLOYED
WESTERN NEUROSURGICAL CLINIC MEDICAL EVALUATION QUESTIONNAIRE. Name: Date of Birth. Age: Social Security No.: Driver's Lic.# Occupation: Employer:
Date: IDENTIFICATION: WESTERN NEUROSURGICAL CLINIC MEDICAL EVALUATION QUESTIONNAIRE Name: Date of Birth Age: Social Security No.: Driver's Lic.# Occupation: Employer: ******************************************************************************
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Spine Epidural steroid injections times... Shoulder/Elbow/Wrist JOINT injections Hip/Knee/Foot JOINT injections
Referring Provider: Main complaints: NAME NAME: _ DATE: Last First M.I. BIRTHDATE: / / AGE: GENDER: Male Female (Check all that apply) Neck pain. Back pain. Joints pain. PHONE Check box if you want to
PATIENT CONSULTATION WORKSHEET
PATIENT CONSULTATION WORKSHEET Today s Date: Name: Referred By: Birthdate: Address: City: State: Zip: Home Phone: Work: Ext: Cell Phone: E-Mail Address: Best way for us to keep in touch with you (check
Patient Name: Date of Birth:
Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?
DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM
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PULMONARY MEDICINE PATIENT QUESTIONNAIRE
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Consent to Treat a Minor
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CONSULTATION ADMITTANCE FORM
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