Please take the time to answer all questions that apply to your problem as completely as possible. Thank You.
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- Gervais Fitzgerald
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1 USC Center for Spinal Surgery New Patient History Form Please take the time to answer all questions that apply to your problem as completely as possible. Thank You. Date Referring Doctor/Primary Doctor Name Chief Complaint Age Date of Injury Injured at County of Time of Injury When did the symptoms originally begin? Did your pain start gradually? Suddenly? Are your symptoms now worse? Better? No Change? What is the degree of pain that you are currently experiencing: none mild moderate severe What is your pain on a scale of 1-10, with 10 being the worst pain? How often do you experience the pain: intermittent constant Describe the quality of your pain (i.e. dull, burning, sharp, etc.) What is your back pain to leg pain ratio? (i.e. 100% back/0% leg)? 100/0 90/10 80/20 70/30 60/40 50/50 40/60 30/70 20/80 10/90 0/100 What is your neck pain to arm pain ratio? (i.e. 100% neck/0% arm)? 100/0 90/10 80/20 70/30 60/40 50/50 40/60 30/70 20/80 10/90 0/100 Where is your pain located? neck neck and arm(s) R or L Arm(s) only- R or L back back and leg(s) R or L Leg(s) only- R or L
2 What aggravates your pain? (standing, sitting, etc.) What relieves your pain? (lying down, sitting, etc.) Do you have night pain? Does it wake you up from sleep? Do you have numbness? If so, where? Do you have weakness? If so, where? Do you have any bowel or bladder problems? incontinence constipation hesitancy Are there any associated signs or symptoms (i.e. nausea, loss of balance, etc.) What treatments in the past have made your pain better? What treatments in the past have made your pain worse? Have you been in a physical therapy program? yes no When/Where/How often? Did it help you? Are you currently working? no yes what type Full Duty Modified Duty Date last worked Are you able to perform your usual duties? WORK COMP INFORMATION Employer at time of injury Job description Length of time on job Job title Movements required for your job: twisting pushing pulling sitting standing stooping crawling lift pounds bending crouching climbing stairs grasping balancing squatting kneeling climbing ladders reaching above shoulders repeated wrist/hand movements Sitting time Standing time Machines used Describe how you were injured If work comp, who is your attorney? If work comp, who is your case manager?
3 MEDICAL/SURGICAL HISTORY Have you had spine surgery in the past? How many? Please list types of spine surgeries and dates/doctor/hospital of surgeries: Please list all medical problems: high blood pressure rheumatoid arthritis thyroid stroke diabetes heart attack asthma stomach ulcer cancer what type seizure kidney stones blood clots in leg or lungs Please list other previous surgeries/year: Tonsils head/neck cancer brain surgery appendectomy cardiac/heart lung cancer ulcer gall bladder kidney bladder abdominal cancer prostate hernia hysterectomy hip/knee replacement shoulder peripheral vascular knee ankle elbow wrist c-section melanoma hand foot hip fracture infection Current medications: Have you tried Anti-inflammation medications (ibuprofen, etc.) Does it help? Does it upset your stomach? Allergies: Are you married? Children? Who do you live with at home? Do you smoke? How much? (pack/day) Do you drink alcohol? How much? Review of symptoms: fever chills sore throat weight loss night sweats headaches blurred vision double vision coordination loss fainting shortness of breath chest pain palpitations dizziness loss of consciousness bloody stools stomach pain diarrhea tarry stools light color stools pain in joints joint swelling bloody urine severe stiffness other:
4 Who referred you to this office? What other doctors have seen you and/or treated you for this problem? What has happened since your last exam? Have you had any recent tests or X-rays? yes no What tests? MRI CT scan Bone Scan Other Mark the areas on your body where you feel the described sensations. Use the appropriate symbol. Mark the areas of radiation. Include all affected areas. Just to complete the picture, please draw your face.
5 -----Patients, please do not write below this line----- SPINE EXAMINATION Constitutional: Appearance Weight Psychiatric: HEENT: Lymphatic: Skin: Incisions: normal/intact healed healing other Musculoskeletal: Alignment/Scoliosis/Rib Hump Gait Heel/Toe Walk Tandem Heel/Toe Raise Myelopathy Cranial nerves: Palpation: nontender tender Carotid bruit ROM: Neck- Flexion Ext Rot Lat Flexion Back- Flexion /90 Extension /30 Sidebending/Rotation Shoulder/Elbow/Wrist ROM Normal Abnormal Hip/Knee/Ankle ROM Normal Abnormal Neurologic: Strength: C5 C5, C6 C7 C6 C7 C8 T1 D B T, ECU WE/ECRL/L WF/FCR FF/FDSP/FCU IO R L L1,L2 L2,L3,L4 L3 L4 L5 L5 S1 HF/IP HADD Q TA EHL, EDL HABD GS,FHL,HE R L Sensory: intact not intact location Vibratory: inatct not intact location Pulses: RUE LUE RLE LLE DTR: Biceps Triceps Brachiorad Knee Ankle R L Cross Adductor Tibialis Abdominal Special Tests: Babinski Clonus Hoffmans Sh Abd Test Adsons Spurling SLR Leseague CRAM FABER Rectal Exam BCR XRAY/MRI Findings: DIAGNOSIS: RECOMMENDATIONS: PT Meds RTC DISABILITY STATUS:
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PATIENT INTRODUCTION
PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via
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.
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
Back and Neck Pain Questionnaire
www.orthonc.com Back and Neck Pain Questionnaire Please print legibly in black ink. Answer only questions applicable to your condition. Leave other spaces blank. Date you are filling out this form: PERSONAL
NEW SPINE PATIENT. Date Seen: Blood Pressure: Pulse: Weight: Height: O 2. How long (days, weeks, or years) has this complaint/problem been going on?
ROOM #: NEW SPINE PATIENT Date Seen: Blood Pressure: Pulse: Weight: Height: O 2 Sats: For office use only above this line. Patient Name: Referring Physician: Date of Birth: Age: Insurance Carrier: Present
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status: