Neurosurgical Clinic of Cedar Rapids
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- Sherman Riley
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1 Neurosurgical Clinic of Cedar Rapids Name: _ Today s Date: Birth date: Age: Sex: M F Height: Weight: Name of referring doctor: Name of family doctor: Why are you seeing the doctor today? How long have you been having symptoms? (days, weeks, months, years) Describe present how your symptoms or problems began and give accident date or date of injury if applicable: Date of injury: Place of injury: Is this related to work? Car accident? Sports injury? Accident? Do you have pain? Rate your pain on this scale: None= =extreme/severe Is the pain constant or does it come and go? Is it SHARP? DULL? BURNING? SHOCKING? TINGLING? THROBBING? ACHING? KNOT-LIKE? STIFF? SWOLLEN-FEELING? What brings the pain on or makes it worse? SITTING STANDING WALKING BENDING RUNNING STAIRS DRIVING RISING FROM CHAIR DURING EXERCISE AFTER EXERCISE LYING DOWN AT NIGHT AFTER WORK OTHER: What makes the pain or discomfort better? SITTING LAYING DOWN BENDING/LEANING OVER HEAT COLD (ICE) EXERCISE BRACE MEDICATION: How long can you sit? Stand? How far can you walk? Do you have any weakness or numbness in the arms or legs? Have you lost control of bowel or bladder function? Have you had any of these tests? If so, when? Shade your areas of symptoms on this diagram. X-rays: MRI: Pain: XXX Numbness/Tingling: 000 CT/Myelogram: EMG: Have you done physical therapy? For how long? What did they do? EXERCISE MASSAGE HEAT ULTRASOUND AQUATICS TRACTION Did therapy help? Explain. Have you had any injections? If so, when and by whom? Epidural steroid injection: Facet injections: What medication have you taken for this problem: Have you had surgery for this problem in the past? If YES, please list procedures, when performed and by whom:
2 PAST MEDICAL HISTORY List any medical problems you have: List your medications: Name Dose Do you have any allergies? Please list medications and reactions OR circle NO ALLERGIES: List any major surgeries or hospitalizations: Complications, if any: Have you ever had general anesthesia (been put to sleep)? YES NO Were there any problems? If YES, please explain: FAMILY HISTORY Are there any illnesses/diseases that run in the family? If YES, explain: SOCIAL HISTORY Do you smoke? YES NO Amount Did you quit? YES NO When? Yrs smoked Do you drink alcoholic beverages? YES NO AMOUNT: Social only Other Do you have a history of any substance abuse or addiction? YES NO Marital Status: SINGLE MARRIED DIVORCED WIDOWED Do you have children? Do you live alone or with others? Education: Jr High School GED High School College Graduate School Other Occupation: Are you working now? YES NO If no, date stopped: Is the reason for discontinuing work due to this present illness or other problem? If other, please explain: 2
3 REVIEW OF SYSTEMS Do you currently or have you had problems with your: If any are checked YES, please clarify. CIRCLE CIRCLE Yes No EYES BLURRED VISION DOUBLE VISION LOSS OF VISION CONTACTS/GLASSES/LASIK Yes No EARS/NOSE/THROAT HEARING LOSS RINGING EARS TROUBLING SWALLOWING DROOLING LOSS OF SMELL OR TASTE VOICE CHANGE NASAL DRAINAGE BLOODY NOSE Yes No CARDIOVASCULAR CHEST PAIN PALPITATIONS IRREGULAR HEART BEAT HIGH BLOOD PRESSURE VARICOSE VEINS SWOLLEN HANDS OR FEET HISTORY OF HEART ATTACK HISTORY OF HEART FAILURE Yes No RESPIRATORY SHORTNESS OF BREATH ASTHMA EMPHYSEMA SPUTUM PRODUCTION SLEEP APNEA Yes No HEMATOLGIC BLEEDING PROBLEMS BRUISE EASILY ANEMIA USE OF BLOOD THINNERS Yes No GASTROINTESTINAL NAUSEA/VOMITING HEARTBURN INDIGESTION ULCERS CONSTIPATION CHRONIC DIARRHEA BLOOD IN STOOLS Yes No GENITOURINARY TROUBLE WITH URINATION INCONTINENCE PROSTATE PROBLEMS TROUBLE WITH ERECTION LOSS OF SEXUAL INTEREST BLOOD IN URINE Yes No MUSCULOSKELETAL JOINT PAIN OSTEOPOROSIS ARTHRITIS RHEUMATOID DISEASE Yes No NEUROLOGIC SEIZURES FAINTING DIZZINESS UNSTEADINESS NUMBNESS/TINGLING WEAKNESS TROUBLE WALKING TROUBLE TALKING CONFUSION MEMORY LOSS Yes No PSYCHOLOGICAL DEPRESSION MANIC-DEPRESSIVE DISORDER ADDICTION Yes No ENDOCRINE DIABETES-HIGH BLOOD SUGAR THYROID PROBLEMS LOW BLOOD SUGAR PROBLEMS Yes No SKIN RASHES SORES SHINGLES PSORIASIS SKIN TUMORS SKIN CANCER Yes No CONSTITUTIONAL FEVER CHILLS UNUSUAL SWEATING LOSS OF APPETITE WEIGHT LOSS FATIGUE HEADACHES HISTORY OF CANCER HISTORY OF HEPATITIS OR HIV/AIDS PLEASE STOP HERE 3
4 HISTORY PRESENT ILLNESS Chief Complaint (SYMPTOMS, PROBLEM, CONDITION, DIAGNOSIS, PHYSICIAN RECOMMENDED RETURN): Sent for consultation by: HPI: Describe symptoms (LOCATION, QUALITY, SEVERITY, DURATION, TIMIMG, CONTEXT, MODIFYING FACTORS, ASSOCIATED SIGNS/SXS): ADDITIONAL HISTORY BY PHYSICIAN OUTSIDE RECORDS REVIEW? YES NO FROM WHERE? 4
5 PHYSICAL EXAMINATION TEMPERATURE BP Pulse Ht Wt GENERAL APPEARANCE (development, habitus, grooming, deformities): WDWN Male Female HEAD AND FACE: EYES: Discs EARS, NOSE, MOUTH, THROAT: Neck: RESPIRATORY: CARDIOVASCULAR: Carotids R Negative/Normal Positive/Abnl L Negative/Normal Positive/Abnl Heart Abnormal sounds: Negative/Normal Positive/Abnl Murmur: Negative/Normal Positive/Abnl Peripheral UE Swelling Negative/Normal Positive/Abnl Pulses Negative/Normal Positive/Abnl Tenderness Negative/Normal Positive/Abnl LE Swelling Negative/Normal Positive/Abnl Pulses Negative/Normal Positive/Abnl Tenderness Negative/Normal Positive/Abnl Varicosity Negative/Normal Positive/Abnl GI: GU: MUSCULOSKELETAL: Gait and Station: Muscle Tone (note any atrophy or fasciculations): RUE Negative/Normal Positive/Abnl LUE Negative/Normal Positive/Abnl RLE Negative/Normal Positive/Abnl LLE Negative/Normal Positive/Abnl Muscle Strength (Grade 0-5): R L Deltoid Bicep Tricep Grip Interossei Finger ext Finger flex Ileopsoas Quadriceps Knee flexion Ankle DF Ankle PF SLR/Laseque: SI tenderness: SN tenderness: Spurlings: Lhermitte s: Patrick s: 5
6 ROM: Neck: Shoulders: Hips: Low back: NEUROLOGICAL: Cranial Nr Orientation: Normal ABNL II VF/acuity INTACT ABNL Memory: Normal ABNL III,IV,VI PERRLA/EOMI INTACT ABNL Short term Long term Attention/Conc: Normal ABNL V V1, V2, V3 INTACT ABNL Serial 7 s Language: Naming VII Motor function INTACT ABNL: Repetition VIII Hearing INTACT ABNL: Comprehension IX Gag INTACT ABNL: Knowledge: XI Shoulder shrug INTACT ABNL: Mood/affect: X Tongue protrusion INTACT ABNL: Sensation: Intact DTR ABNL(identify modality and where): Coordination: FTN HTS Dysmetria Ataxia Romberg RADIOLOGIC TESTING MRI scan: CT scan: Myelogram: Xrays: EMG/NCS (report reviewed): Unless checked, images were personally reviewed by MD. IMPRESSION/DIAGNOSIS RECOMMENDATIONS/TREATMENT/COUNSELING/FOLLOW-UP Medication: Further studies: PT/exercises: Consults: Surgery: I verify that I have discussed with the patient and/or designee the risks, benefits, options, and alternatives to the above operation/procedure/plan. Follow-up: I have reviewed all data in this record and agree. Signature: Date: Discussing with referring physician Discussion with consultant More than 50% time counseling 6
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