THE METROPOLITAN NEROSURGERY GROUP PATIENT REGISTRATION Today's Date: / / Primary Care Physician: PCP Address:
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1 THE METROPOLITAN NEROSURGERY GROUP PATIENT REGISTRATION Today's Date: / / Primary Care Physician: PCP Address: PCP Phone: PATIENT INFORMATION LAST NAME FIRST NAME MI Mr. Mrs. Miss Ms. Single Married Widow Divorce / Separate DATE OF BIRTH GENDER: ETHNICITY (OPTIONAL) / / M F White African American Hispanic Asian Native American Other ADDRESS P.O. BOX: or: STREET ADDRESS: CITY: STATE: ZIP: SOCIAL SECURITY NO: - - OCCUPATION: HOME PHONE: CELLULAR: Who referred you to us? Who is your geneticist? Send letter (visit note) to? Preferred Pharmacy Name and Address: Pharmacy phone no: Height: Weight: lbs. BP (leave for staff): / HR (leave for staff): / min List the 3 top concerns that you would like to discuss today: Imaging, tests or reports brought for review today:
2 PAIN ASSESSMENT: Using the diagrams below, please indicate pain location, type, frequency and intensity. PAIN TYPE: FREQUENCY + aching pins and needles continuous numb dull/throb on and off sharp nerve pain
3 PLEASE LIST ANY CONSERVATIVE TREATMENTS THAT YOU HAVE TRIED SO FAR: PHYSICAL THERAPY: Does your physical therapist specialize in EDS/Hypermobility? OCCUPATIONAL THERAPY: Does your therapist specialize in EDS/Hypermobility? OTHER TYPES OF THERAPY (aqua, massage, dry needling, acupuncture, etc): Type of procedure/treatment: Does your therapist specialize in EDS/Hypermobility? NERVE BLOCKS AND EPIDURAL INJECTIONS: Date(s): Type of block/injection OTHER PROCEDURES/TREATMENTS (BACLOFEN PUMP, TENS UNIT, etc.): Type of procedure/treatment: BRACES: Type of brace: OTHER PROCEDURES, TREATMENTS OR MEDS (e.g. medications you have tried in the past for related symptoms, such as neurogenic bladder, chronic constipation/gastroparesis, nausea, POTS, etc). Describe your response to treatment:
4 PLEASE LIST ALL MEDICATIONS THAT YOU HAVE TRIED FOR PAIN SO FAR: NARCOTIC PAIN MEDICATIONS (e.g.: Oxycodone, Oxycontin, Dilaudid, Morphine Sulfate, Fentanyl patches, Percocet, Methadone, Marinol, etc) : Drug Dose Frequency Length of treatment Response to treatment Are you still taking it? Yes No Yes No Yes No ORAL CORTICOSTEROIDS (e.g.: Medrol, Solucortef, Cortisone, Prednisone, Prednisolone, Methylprednisolone, Decadron, etc) Drug Dose Frequency Length of treatment Response to treatment Are you still taking it? Yes No Yes No Yes No N.S.A.I.D.S (e.g.: Aspirin [Bufferin, Bayer, and Excedrin], Ibuprofen [Advil, Motrin, Nuprin], Ketoprofen [Actron, Orudis], Naproxen [Aleve], Daypro, Indocin, Lodine, Naprosyn, Relafen, Vimovo, Voltaren, Celebrex, Ketorolac, etc) Drug Dose Frequency Length of treatment Response to treatment Are you still taking it? Yes No Yes No Yes No OTHER PAIN MEDICATIONS (e.g.: pain creams, lidocaine patches, Tylenol, etc) Drug Dose Frequency Length of treatment Response to treatment Are you still taking it? Yes No Yes No Yes No
5 OTHER MEDICATIONS (please print) Nr. Medication Dose Frequency Prescribing Physician Taking since (year) ALLERGIES Nr. Allergen Reaction Mild Moderate Severe
6 HISTORY Social History (check all that apply) Living arrangements live alone does not live alone Occupation/Exposure agricultural office work other exposure Activities of daily use a cane use a walker use a wheelchair problems using toilet living no problems using toilet rely on others for transportation Foreign travel/living has recently traveled outside U.S. Exercise regularly occasionally rarely never Education currently attending school Employment status working full time working part time disabled retired not working Smoking Hx: active smoker: # of cigarettes/day: for: years. former smoker: # of cigarettes/day: for: years; stopped: years ago. never smoked. Alcohol consumption: never socially (2-3 times a year) occasionally (2-3 times a month) frequently (2-3 times a week) 1 drink daily* 2-3 drinks daily* more than 3 drinks daily* * one glass of wine/one beer/one shot glass of liquor are considered one drink. Recreational drugs use: current user: type of drug: frequency: last time used: former user: type of drug: frequency: last time used: never used
7 HAVE YOU EVER BEEN DIAGNOSED WITH: Ehlers Danlos Syndrome (EDS) or other connective tissue disorder? NO YES: when did you experience the first symptoms? any precipitating event? year the diagnosis was made: by: Chiari Malformation? NO YES: when did you experience the first symptoms? any precipitating event? year the diagnosis was made: by: Tarlov Cyst? NO YES: when did you experience the first symptoms? any precipitating event? year the diagnosis was made: by: Other Medical History ILLNESS Onset (year) Related to today s visit?
8 Family Medical History Relative (e.g. mother, L: living father, etc.) D: deceased Age Illness(s) Surgical History Surgery Year
9 Indicate severity using number scale 1 = None or Minimal 2 = Mild 3 = Moderate 4 = Severe 5 = Incapacitating NEUROLOGICAL MUSCULOSKELETAL Hyperaccusis/sensitivity to noise Neck pain on bumpy roads Ringing in the ears Muscle pain at rest Loss of hearing Cramps/stiff muscles Balance disorder Pain in legs while walking Vertigo (room spinning around) Back pain standing/walking Dizziness/lightheadedness Back pain when lying down Shaking episodes Back pain walking up incline Seizures Lower back pain Tremors Sacral pain Headache Sleep with knees bent Neck pain CARDIOVASCULAR/AUTONOMIC NERVOUS SYSTEM Loss of consciousness/syncope Feeling heart beats/palpitations Concentration difficulties Chest tightness/pain at rest Memory loss Chest pain on exertion Blurred vision Shortness of breath at night Double vision Shortness of breath at rest Teichopsia (vision flashes) Shortness of breath on exertion Photosensitivity (light sensitivity) Fingers change color Foreign body sensation in eye Excessive sweating Hyperolfaction (sensitivity to smell) Heat intolerance Facial numbness Fever Paresthesia/tingling/sensory loss Changes in sleep pattern Leg weakness Abnormally dilated pupils Arm weakness GASTROINTESTINAL Nausea/vomiting Abdominal pain Poor coordination Bloating Speech difficulty Constipation Hoarseness Heart burn Choking Diarrhea Difficulty swallowing Black stool/blood in stool CONSTITUTIONAL Loss of bowel control Fatigue GENITOURINARY Rashes Burning with urination Easily bruised Increased frequency / urination Joint pain Loss of bladder control Poor wound healing Nocturia (urination at night) Frequent infections Difficulty initiating stream Anemia Unable to empty bladder Excessive bleeding Scoliosis Change in appetite PSYCHIATRIC Weight loss Depression Swollen lymph nodes Anxiety/panic Thyroid disorder Hair loss
10 OTHER PERTINENT INFORMATION YOU WOULD LIKE TO ADD:
THE METROPOLITAN NEROSURGERY GROUP LLC FOLLOW UP QUESTIONNAIRE. P.O. BOX: or: STREET ADDRESS: CITY: STATE: ZIP:
THE METROPOLITAN NEROSURGERY GROUP LLC FOLLOW UP QUESTIONNAIRE DATE: / / FIRST NAME LAST NAME D.O.B. POST OP. (within 3 months of surgery) YES NO LAST VISIT DATE: MOST RECENT SURGERY DATE: Type: Primary
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