Spine Pain Management Program
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1 Spine Pain Management Program Please complete the following information: Patient Name: Patient ID Number: Patient DOB: The procedure being requested: Epidural Injection Please check the indication (reason) for this procedure and complete the form below: Epidural Injection with no indication Epidural Injection with serious spinal pathology Epidural Injection with radiculopathy with incapacitating or severe persistent radicular pain Epidural Injections for the treatment of axial back pain Epidural Injections for the treatment of neurogenic claudication
2 Requested Procedure Please indicate the spinal levels on which this procedure will be performed C T L History Please enter the date of onset for current episode M M D D C C Y Y Requested Procedure What is the primary spinal region involved? (choose only one) Cervical Thoracic Lumbosacral Please indicate on which side the injection will be performed Right Left Bilateral t applicable Additional Information Please indicate the approach that will be used. Transforaminal Interlaminar Caudal Indicate Signs and Syptoms Please indicate the symptom(s) associated with this spine condition Neck pain Mid-back pain Lumbosacral pain SI pain Radicular pain Neurogenic claudication Paresthesia Please indicate the severity of these symptoms Severe Very severe Incapacitating Please assess the patient's overall physical function Very good Good Moderate Poor Very poor Diagnostic Testing Please indicate the type of diagnostic testing previously performed for this condition CT MRI CT-Myelography X-rays Bending/Dynamic x-rays Bone scan/spect Needle EMG Nerve conduction testing H-reflex testing Sensory evoked potential Spinal biopsy Nerve root block Page: 01
3 Please indicate the findings reported by this diagnostic testing Myelopathy Cauda equina Fracture Malignancy Infection Spondyloarthropathy Severe Instability Central stenosis Nerve root compression Spondylolisthesis Deformity Hardware failure Pseudoarthrosis Inconclusive Please indicate the spinal levels on which these findings were reported Additional Information Please indicate if the clinical presentation is consistent with findings on diagnostic imaging Indicate Neurologic Signs Please indicate the neurologic sign(s) associated with this spine condition Focal weakness Widespread weakness Atrophy Gait disturbance Pathologic reflex Clonus Spasticity Please indicate the severity of these neurologic signs Severe Very severe Progressive Indicate Neurological Motor Deficits Please indicate if neurological motor deficits are present Please indicate the spinal nerve root(s) affected by the motor deficit Please indicate the severity of the motor deficit Severe Very severe Incapacitating Specify Prior/Conservative Care Please indicate the clinician(s) who delivered primary/conservative care for this spine condition PCP Medical Specialist Surgeon Physical Therapist Chiropractor Massage Therapist Other Page: 02
4 Please indicate the primary/conservative care intervention(s) received for this spine condition NSAIDs n-opioid Analgesics Opioids Patient Education Supervised Exercise Spinal Manipulation Muscle Relaxants Other Medications Heat Ice Physical Modalities Massage Other Please indicate the number of weeks of primary care received since the date of onset Please assess the improvement in symptoms noted since initiating primary/conservative care ne 1-10% 11-20% 21-30% 30% or more Please assess the improvement in function noted since initiating primary/conservative care ne 1-10% 11-20% 21-30% Over 30% Specify Prior Epidural Injection Has an epidural injection previously been performed for this spine condition? Please indicate the date on which an epidural injection was last performed M M D D C C Y Y Please indicate the spinal levels in which an epidural injection was last performed Please assess the overall improvement in symptoms with the epidural injection 0% 1-20% 21-30% 30% or more Please assess how long the improvement in symptoms lasted < 2 weeks 2-4 weeks 4-6 weeks 6-8 weeks 8 weeks or more Please assess the overall improvement in function with the epidural injection 0% 1-20% 21-40% 41-50% 51% or more Page: 03
5 Please assess how long the improvement in function lasted < 2 weeks 2-4 weeks 4-6 weeks 6-8 weeks 8 weeks or more Contraindications Please indicate if there are any contraindications to this procedure What are they? Page: 04
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