NAME: DATE: SPINE CENTER NEW PATIENT QUESTIONNAIRE
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- Pamela Barker
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1 Please complete and give to the receptionist when you arrive at the office for your appointment. NAME: DATE: SPINE CENTER NEW PATIENT QUESTIONNAIRE Page 1 of 6 Primary Care Physician s Name Primary Care Physician s Phone Fax Who referred you to the Spine Center? Your age Right handed Left handed If you are having pain, where are your symptoms located? (check all that apply) Average pain intensity in the last week Neck No Pain Severe Pain Right Arm No Pain Severe Pain Left Arm No Pain Severe Pain Mid Back No Pain Severe Pain Low Back No Pain Severe Pain Right Leg No Pain Severe Pain Left Leg No Pain Severe Pain Are you experiencing: Arm or leg numbness No Yes Arm or leg weakness No Yes Bladder problems No Yes Pain with walking No Yes If Yes, how many minutes can you walk? When did your symptoms begin? / / Were you injured at work? No Yes Date Were you injured in a motor vehicle accident? No Yes Date Can you recall a specific event associated with the onset of your symptoms? No Yes If yes, describe? (This space for Doctor s only) MS 732 Rev 07/17
2 Page 2 of 6 Have you ever had pain or problems in these areas before? No Yes Have you had any prior spine surgery? No Yes If yes, how many operations? Have you had any diagnostic test? (Please bring all diagnostic studies and reports for your Spine Center Visit.) X-Rays MRI CT Scan Are you currently taking any medications for your pain symptoms? (List only medications used for pain.) Name Dosage Does it help? Side Effects? Have you had any of the following treatments for your symptoms? (Please Check) Physical therapy Chiropractic Acupuncture Epidural Injections Facet Injections Nerve root blocks Other treatments In and average week, how often do you: Never or more Stretch your back or neck? Exercise your back or neck? Lift weights for your back or neck? Perform aerobic exercises? What is your current work status? Not working because of pain Working but reduced hours or intensity because of pain Working to desired capacity despite pain Disabled from working because of other health problems If you are out of work, for how long? Unemployed, but looking for work Unemployed, by choice/ Homemaker Retired Student What is your occupation or profession? Include elementary, high school, college, etc, how many years of school have you attended? Because of your pain, are you currently receiving: Workers Compensation No Yes Applying for workers compensation Social Security Disability No Yes Applying for social security disability benefits Private Disability No Yes Applying for private disability benefits Have you hired a lawyer to help with you legal issues concerning your pain? No Yes Are you involved in a personal injury lawsuit because of your pain? No Yes Unsure MS 732
3 Page 3 of 6 This questionnaire is designed to give us information as to how your back (or leg) trouble affects your ability to manage in everyday life. Please answer every section. Mark one box only in each section that most closely describes you today. Section 1 Pain Intensity I have no 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. Section 6 Standing I can stand as long as I want without extra pain. I can stand as long as I want but it gives me extra pain. Pain prevents me from standing for more than 1 hour. Pain prevents me from standing for more than ½ hour. Pain prevents me from standing for more than 10 minutes. Pain prevents me from standing at all. Section 2 Personal care (washing, dressing, etc.) I can look after myself normally without causing extra pain. I can look after myself normally but it is very painful. It is painful to look after myself and I am slow and careful. I need some help but manage most of my personal care. I need help every day is most aspects of self care. I do not get dressed, wash with difficulty and stay in bed. Section 7 Sleeping My sleep is never disturbed by pain. My sleep is occasionally disturber by pain. Because of pain I have less than 6 hours sleep. Because of pain I have less than 4 hours sleep. Because of pain I have less than 2 hours sleep. Pain prevents me from sleeping at all. Section 3 Lifting I can lift heavy weights without extra pain. I can lift heavy weights but it gives extra pain. Pain prevents me from lifting heavy weights off the floor but I can manage if they 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. Section 4 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 100 yards. I can only walk with a cane or crutches. I am in bed most of the time and have to crawl to the bathroom. Section 5 Sitting I can sit in any chair as long as I like. I can 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. Section 8 Sex Life (if applicable) My sex life is normal and causes no extra pain. My sex life in normal and causes some extra pain. My sex life is nearly normal but is very painful. My sex life is severely restricted by pain. My sex life is nearly absent because of pain. Pain prevents any sex at all. Section 9 Social Life My social life is normal and causes me no extra pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interest, e.g. sports, etc. Pain has restricted my social life and I do not go out as often. Pain has restricted my social life to my home. I have no social life because of pain. Section 10 Traveling I can travel anywhere without pain. I can travel anywhere but it gives extra pain. Pain is bad but I manage journeys over 2 hours. Pain restricts me to journeys of less than one hour. Pain restricts me to short necessary journeys less than 30 minutes. Pain prevents me from travelling except to receive medical treatment. (ODI 2.0) Score _/_=_% MS 732
4 Page 4 of 6 Please circle Y of N if you currently have the problem in the first column. If you do not have the problem, skip to the next problem. If you do have the problem, please indicate in the second column if you receive medications or some other type of treatments for the problem, and list them in the third column. Then in the fourth column, indicate if the problem limits any of your daily activities. Finally, at the end please of page list all additional medical conditions and daily medication. PROBLEM Do you have the Do you receive List medications Does it limit problem? treatment for it or treatment your activities Heart Disease Y N Y N Y N High blood pressure Y N Y N Y N Lung disease Y N Y N Y N Diabetes Y N Y N Y N Ulcer or stomach disease Y N Y N Y N Kidney disease Y N Y N Y N Liver disease Y N Y N Y N Anemia or other Y N Y N Y N blood disease Cancer, Type Y N Y N Y N Date of Diagnosis Depression / Anxiety Y N Y N Y N Osteoarthritis Y N Y N Y N (degenerative arthritis other than spine) Chronic pain in other areas Y N Y N Y N Where Rheumatoid arthritis Y N Y N Y N Glaucoma Y N Y N Y N List other medical problems and daily medications Y N Y N Y N Y N Y N Y N Y N Y N Y N Do you regularly take Aspirin? Blood thinners? Anticoagulants? MS 732
5 Page 5 of 6 Have you ever been hospitalized for a medical or psychiatric illness? Please list any surgeries Please list all allergies to medications Do you use tobacco? No Yes Packs per day Total Years Do you drink alcohol? No Yes How many drinks per week? Marital status Children Grandchildren Hobbies and non-work activities Have you ever felt unsafe at home? No Yes Have you ever been harmed (hit) or threatened by someone close to you? No Yes Is there anything occurring in your family or home life which is upsetting you? No Yes What is your height? Weight? Do you have any of the following problems? (Please check) Headaches Cancer Seizures, Stroke, Brain Injuries Recent fever, chills, night sweats Loss of concentration, memory problems Prolonged, persistent or recent infection Visual or hearing impairments, glaucoma Bleeding tendencies Loss of coordination, tremor, balance problems Blood clots, phlebitis Asthma or respiratory problems Anemia or blood disorders Chest pain, heart diseases, hypertension, murmurs, Thyroid or other hormonal problem arrhythmias Loss of appetite Elevated cholesterol Unexplained weight loss Abdominal pain Depression Stomach problems, ulcers, hiatal hernias Anxiety Colitis, irritable bowel, digestive problems Stress Hepatitis or liver disease (For Women) Diabetes Menstrual difficulty or possibility of pregnancy Rheumatoid Arthritis Abnormal Pap smear Osteoarthritis Abnormal mammography Osteoporosis (For Men) Date of last bone density Prostate problem Kidney, urine or bladder problems Abnormal PSA Pelvic pain Does anyone in your family have a history of: Heart disease Cancer Neuropathy of Neurological problems Arthritis Disc herniation Spinal Stenosis Spine surgery Chronic pain Scoliosis X Patient Signature MS 732 Rev. 7/17 Print Name Date Time am / pm
6 Page 6 of 6 CERVICAL MAXIMUM ( o ) PAINFUL FLEXION EXTENSION SIDE FLEXION R L R L ROTATION R L R L PALPATION SHOULDER ELBOW RIGHT NEUROLOGICAL MOTOR (GRADE 1-5) SENSORY (PIN PRICK) RIGHT RIGHT C-5 BICEPS C-6 PRONATOR C-7 TRICEPS C-8 INTRINSIC T-1 ADM REFLEXES BICEPS BRACHIORADIALIS TRICEPS FINGER HOFFMAN RIGHT THORACIC SPINE MAXIMUM ( o ) PAINFUL ROTATION RIGHT ROTATION DEFORMITY LUMBAR (STANDING) MAXIMUM ( o ) PAINFUL FLEXION EXTENSION SIDE FLEXION R L R L RIGHT HIP KNEE ROOT TENSION SIGNS STRAIGHT LEG RAISING ( o ) PAIN RIGHT FEMORAL STRETCH RIGHT NEUROLOGICAL MOTOR (GRADE 1-5) SENSORY (PIN PRICK) RIGHT RIGHT QUAD L2 DORSI L3 E H L L4 HIP ABD L5 CALF S1 REFLEXES PATELLA ACHILLES BABINSKI CLONUS RIGHT WADDELL OVER REACT SUP TEND DIS SLR SIMUL ROT GLOBAL SCAR: POSTURE: GAIT: VASCULAR RIGHT ATROPHY RIGHT PALPATION X Provider Signature / Credentials MS 732 Rev. 7/17 Print Name Date Time (24 hours)
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SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT
Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
2105 Braxton Lane, Suite 101 Greensboro, NC Premier Drive High Point, NC Phone: (336) Fax: (336)
2105 Braxton Lane, Suite 101 Greensboro, NC 27408 4590 Premier Drive High Point, NC 27265 Phone: (336) 333-6306 Fax: (336) 333-6309 Date: Patient Name: (please print) Date of Birth: (month/day/year) Gender:
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
Baylor Physical Medicine and Rehabilitation NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny Dear Patient: Please complete this questionnaire before you come for your appointment. Be sure to call us as soon
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
Medical History Questionnaire
Date Medical History Questionnaire Name DOB Reason for visit When did symptoms first appear Is the condition getting worse? Please rate your pain 0 1 2 3 4 5 6 7 8 9 10 No Pain Extreme Pain Please circle
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
Name Date Date of Birth Last Name First Name Middle Initial. Employment Information
Zindt Chiropractic Center 3819 S M St Workmen s Compensation Tacoma, WA 98418 Information Name Date Date of Birth Last Name First Name Middle Initial Employment Information Employer s business name (at
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: ******************************************************************************
INITIAL PAIN EVALUTION QUESTIONNAIRE
INITIAL PAIN EVALUTION QUESTIONNAIRE We are interested in understanding more about your pain. Please help us by filling out this questionnaire. Please bring the completed questionnaire with you for your
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician
Current Problem Date Name (First, MI, Last) Date of Birth Age Male Female Primary Care Physician Referring Physician Height (feet/inches) Weight (lbs.) Right Handed Left Handed Both Current Problem: Right
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Last Name First Name Middle Name MRN
Dr. Byers Dr. Su Dr. Sponzilli Lisa Elvin, NP Spine Center New Patient Form Last Name First Name Middle Name MRN This form is used to gather information so that my doctor can maximize the time used to
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM First Name MI Last Preferred Name Date of Birth / / Age Gender Patient/Guarantor SS# - - Email Address Martial Status Single Married Other Street Address City State Zip Code Profession
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
SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD
Name: Height: Birthdate: Weight: Chief Complaint: What is the reason for your appointment? (please describe why you are here) Medications: Please list ALL medications with dosages you are currently taking,
Samuel A. Joseph, Jr., M.D. In order to be seen by one of our physicians, you must bring the following to your visit:
Samuel A. Joseph, Jr., M.D. Your appointment has been scheduled: Your appointment time is: Please arrive at: o o o 2727 West Dr. Martin Luther King Jr. Blvd. Suite 590 Tampa, FL 33607 1840 Mease Drive
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM Which Chiropractor are