CSC Physicians: Ulrich Batzdorf, MD; David E. Fish, MD; Langston Holly, MD; Jae Jung, MD; Duncan Q. McBride, MD; Nick Shamie, MD; Daniel Lu, MD, PhD
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1 CSC Physicians: Ulrich Batzdorf, MD; David E. Fish, MD; Langston Holly, MD; Jae Jung, MD; Duncan Q. McBride, MD; Nick Shamie, MD; Daniel Lu, MD, PhD COMPREHENSIVE SPINE CENTER Arya Nick Shamie, M.D Wilshire Blvd, Suite 100 Santa Monica, CA (310) 319-DISK (clinical appt); (424) (fax) Dear Esteemed Patient: Thank you for choosing to make an appointment at the UCLA Spine Center located at 1131 Wilshire Blvd, Suite 100 in Santa Monica. Please be sure to bring the following to your appointment: Your most current diagnostic films and reports (e.g. MRI, CT, plain x-rays; SSEP or EMG reports; Physical Therapy reports; Pain Medicine reports, etc.) pertaining to your current medical condition. (PLEASE NOTE: If your Films were done within the UCLA system at Santa Monica or Westwood, our office will make sure that they are here for your visit and you do not need to pick up these films. However, if you had films done outside of UCLA, you do need to bring these with you). Prior medical records and consultations from your referring physician and any other specialist you've seen for your current condition. To help expedite your visit, please hand carry your reports to this office. Do not send them prior to your appointment. Your medical insurance card (s) If you have HMO Insurance: Please be sure to bring your "Letter of Authorization: from your HMO. If you do not bring your authorization letter and we do not have written authorization on file, you will be financially responsible and will be asked to pay the consultation fee on the day of your appointment. If you have HMO Insurance: Please be sure to bring your co-payment with you. We accept cash, check, or Visa/Mastercard. Attached you will find a questionnaire and a map with directions to our location. Please bring in the completed paperwork to your appointment. If you have any questions, please feel free to contact the UCLA Spine Center Appointment Scheduling desk at (310) We look forward to seeing you. PLEASE NOTIFY US OF ANY CANCELLATIONS AT LEAST 24 HOURS PRIOR TO YOUR APPOINTMENT On your initial visit you will be seen by spinal neurosurgeon, Arya Nick Shamie, M.D., of the UCLA Comprehensive Spine Center, in Santa Monica. He will, with or without a Spine Fellow and /or Resident and /or Physician's Assistant and /or Nurse Practitioner student, obtain a medical history and perform a physical examination. The SM/UCLA Comprehensive Spine Center advocates a multi-disciplinary approach to strive and attain the best possible healing and recovery for every patient. Because every patient is unique, we prescribe treatment based on a thorough evaluation, that we perform utilizing the latest technological advancements available. We believe in evaluating patients promptly and educating them on their diagnosis, so they can play an active role in the decision-making and treatment process. Our physicians' clinical experience has shown that patients who participate in their own health care decisions are far more likely to achieve an optimal level of healing and recovery. Sincerely, Patient Care Coordinator SM/UCLA Comprehensive Spine Center
2 Referring Physicians and Other Physicians involved in Medical Care Physician Name: Specialty: Phone Number: Fax Number: Address: Physician Name: Specialty: Phone Number: Fax Number: Address: Physician Name: Specialty: Phone Number: Fax Number: Address:
3 Arya Nick Shamie, M.D. Functional Questionnaire UCLA Comprehensive Spine Center *You may be asked to complete this form on subsequent visits during your treatment Name UCLA number Current Date Please read: This questionnaire has been designed to give the doctor any information as to how your back pain has affected your that ability to manage in every day life. Please answer every section and mark only the one box that applies to you. How long have you had back/neck pain? How long have you had leg/arm pain? Section 1 - Pain Intensity Years Months Weeks I can tolerate the pain without having to use pain killers Pain killers give very little relief from pain Pain killers have no effect on the pain and I do not use them 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 causes extra pain 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 and stay in bed Section 3 - Lifting I can lift heavy weights without extra pain I can lift heavy weights but it causes extra pain Pain prevents me from lifting heavy weights, but I can manageif they are conveniently positioned square 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 my walking any distance Pain prevents my walking more than 1 mile Pain prevents my walking more than 1/2 mile Pain prevents my walking more than 1/4 mile Section 5 - 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 more than 1/2 hour Pain prevents me from sitting more than 10 min. Pain prevents me from sitting at all We realize you may consider that two of the statements one section relate to you, but please mark only the box most closely describes your problem. Section 6 - Standing Paint prevents me from standing more than 10 minutes Pain prevents me from standing at all Section 7 - Sleeping Pain does not prevent me from sleeping well I can sleep well only by using tablets Even if I take medication I have less than 6 hours sleep Even if I take medication I have less than 4 hours sleep Even if I take medication I have less than 2 hours sleep Pain prevents me from sleeping at all Section 8 - Sex Life Normal and causes no extra pain Normal but increases the degree of pain Nearly normal but is very painful Nearly absent because of pain Pain prevents any sex life at all Section 9 - Social Life Normal and give me no extra pain Normal but increases the degree of pain Pain has no significant effect apart from limiting my more energetic interests, e.g. dancing, 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 extra pain I can travel anywhere but it causes extra pain Pain is bad but I manage journeys over two hours Pain restricts me to journeys of less than one hour Pain restricts me to short journeys under 30 min Pain prevents me from traveling except to the doctor or hospital Comments
4 Arya Nick Shamie, M.D. General Medical Review of Systems UCLA Comprehensive Spine Center Allergies Asthma Hay Fever Skin Eruptions Cardiovascular Chest Pain Irregular Heart Beat High/Low blood pressure Poor circulation Rapid Heart Beat Constitutional Chills/sweats/fever Fainting Forgetfulness Headache Loss of sleep Nervousness Weight Loss Ears, Nose, Mouth, Throat Bleeding Gums Diifficulty Swallowing Ear Ache Ear Discharge Hearing Loss Hoarseness Nosebleeds Persistent Coughs Ringing in Ears Sinus Problems Endocrine Rapid Weight Loss/Gain Inolerance to warm room Multiple Broken Bones Cessation of Menstrual period Excessive hunger/thirst Loos of libido Spontaneous Nipple Discharge Eyes Blurred Vision Crossed Eyes Double Vision Vision Flashes or Halos Genitourinary Blood in Urine Lack of bladder control Painful urination Gastrointestinal Bloating Bowel Changes Constipation Diarrhea Gas Hemorrhoids Indigestion Nausea Poor appetite Rectal bleeding Stomach Pain Hematologic/Lympathic Swollen Lymph Nodes Easy Skin Bruising Prolonged Bleeding Integumentary Men Skin Rashes or Eruption Chronic Bleeding Breast Lump Lump in testicle Penis discharge Sore on penis Neurological Fainting Headache Seizures Numbness of arms and legs Tingling of hands, feet arms, or legs Musculoskeletal Pain, Weakness, Numbess, Swelling Hands, Wrists, Hips, Knees, Joints Pain in arms and legs Physchiatric Anxiety Depression Panic attacks Restlessness Respiratory Blood Cough Dizziness Shortness of Breath Women Abnormal Pap Smear Bleeding between periods Breast Lump Extreme Menstrual Pain Hot flashes Nipple Discharge Painful Intercourse Are you Pregnant? Last Mammogram Last Period Last Pap Smear # of Children and Ages
5 Comprehensive Spine Center Medical Information Sheet Arya Nick Shamie, M.D. "Please take some time to carefully fill out these sheets so that we can provide you with the very best care." Name Last Name, First Name, Middle Birthdate (mo/day/year) Age Sex (M/F) Weight Height Right or Left Handed Your Occupation(s): Are you presently (working/disabled/retired)? Are you: Married Single Divorced Separated Widowed In your words, please describe your problem and reason for visiting us today. Symptoms Duration Please tell us what treatments you have had up to now for the problems you described above. Treatment When / How Long Did it help?
6 Please tell us about surgical procedures you have had before. Previous operations Dates Any Problems (y/n?) Please tell us about any other medical problems you may have (examples: hypertension, diabetes, stroke, cancer, etc.) Medical Issue How Long Any Treatment? When? Check box if answer is yes Do you smoke? Do you drink? How many packs per day? What do you drink? For how many years? How often? Osteoporosis Recent Infections Heart Attacks Rheumatoid Arthritis HIV/AIDS Chest Pain Cancer Hepatitis Lung Problems Family History: Parents, Grandparents, Siblings (alive or deceased; list age at date of death and cause) Please tell us ALL medications, pain pills, aspirins, or supplements you are taking or have recently taken. Medication Strength/Amount How many pills and times per day? Allergies to medications Other allergies Please list all recent X-rays, CTs, MRIs, or other studies you have had for your problem. (dates/where) Are you claustrophobic? Have you required sedation in the past? Implants (i.e. stimulators, medication pumps, metal (titanium or steel), include location of implant)
7 Please help us better understand the pain that you are experiencing. Indicate the locations of your pain by shading in the painful areas on these figures >> (After printing out the form) 1. Please indicate the current intensity of your pain by making an X anywhere on the line below: NO PAIN THE MOST INTENSE PAIN IMAGINABLE 2. Please indicate the worst intensity of your pain over the past month by making an X anywhere on the line below: NO PAIN THE MOST INTENSE PAIN IMAGINABLE 3. Please indicate your mood over the past month by making an X anywhere on the line below: EXTREMELY EXTREMELY BAD MOOD GOOD MOOD 4. Please rate how often your pain problem stopped you from doing what you wanted to do over the past month: COMPLETELY STOPPED ME DID NOT STOP ME 5. Please indicate how many days per week you have had adequate relief of your pain over the past month (by indicating a number): 6. If your are taking pain medications, please indicate the amount of relief you receive after taking your medication by making an X anywhere on the line below: NO RELIEF COMPLETE RELIEF 7. Overall, how satisfied are you with the results of your pain treatment? extremely very somewhat mixed somewhat very extremely dissatisfied dissatisfied dissatisfied satisfied satisfied satisfied 8. Check all the words that describe your pain this month: Aching Throbbing Shooting Stabbing Gnawing Fearful Sharp Tender Heavy Burning Exhausting Splitting Punishing Sickening Cramping
8 Health Questionnaire English version for the US US (English) 1998 EuroQol Group. EQ-5D is a trade mark of the EuroQol Group
9 By placing a checkmark in one box in each group below, please indicate which statements best describe your own health state today. Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed 2 US (English) 1998 EuroQol Group. EQ-5D is a trade mark of the EuroQol Group
10 To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today. Best imaginable health state Your own health state today US (English) 1998 EuroQol Group. EQ-5D is a trade mark of the EuroQol Group Worst imaginable health state
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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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Scottsdale Family Health
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Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
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New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
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Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
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Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX Phone (903) Fax (903)
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Other doctors to receive copies of records : Chief complaint / history of present illness (Describe why you have been referred here):
Patient Name: Date: Age: Date of Birth: Preferred Name: Preferred Language: Address: City: State: Zip: Phone: Cell Phone: Preferred Phone: Emergency Contact: Relationship: Email: If you would like to opt
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7. Drug Allergies Yes No If yes, please list drug and reaction (hives, rash, etc.)
Nursing Assessment Form Today s Date Please complete this form so we can identify areas in which to assist you. 1. Name Date of Birth Place of Birth 2. Married Widowed Divorced Never Married 3. Occupation
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McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
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