The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA C
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1 The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA C PEDIATRIC SPINE HISTORY Name of Patient: For Office Use Only: HR: BP: / Date: Date of Birth: Age: Height: ft in Weight: lbs Form Completed By: Relationship to Patient: Referring Doctor Name and Address: What problem is the doctor seeing the patient for today? (Check all that apply) Spinal Deformity: Scoliosis Kyphosis Spondylolisthesis Pain: Neck Pain Arm: Pain Numbness Weakness Back Pain Leg: Pain Numbness Weakness Other (please describe): How long has the pain/problem been present? Was there an injury, and if so, what caused the injury? How severe is the pain at the location described above (circle below): No pain Slight Mild Moderate Severe Excruciating Has the pain/problem worsened recently? No Yes, how recently? Quality of the pain: Sharp Burning Aching Dull What makes the problem better? Worse? Is the pain (check all that apply): Continuous Night pain Activity related Unpredictable Does the patient have numbness or weakness in his/her arms or legs? No Yes If yes, where? Are there any problems with loss of bowel or bladder control? No Yes Are there any problems with balance, fine motor control, or dexterity? No Yes How was your spinal deformity discovered? Do you know your present curve measurements? Reasons for seeking treatment at this time: progressive deformity pain can t stand straight don t like the appearance of back/waistline other: Growth in the past six months: Height of: Mother Father Siblings
2 What treatments have you tried? Physical therapy/exercise TENS unit Narcotic medications Braces Massage/Ultrasound Traction Anti Inflammatories Orthotics Chiropractic treatment Surgery Steroid injections Cast/boot If recommended, please rate how interested you are in having surgery to treat your problem: Not at all Maybe Definitely Previous physicians seen for this problem: Physician Specialty City, State Treatment Medications taken for this problem: Name of Medication Dose Reason X rays and Tests for this problem: Results Date Location X rays MRI CT scan Bone scan Other Because of this problem, have you filed or do you plan to file a lawsuit? Yes No Is there any other information that the doctor should be aware of?
3 WHERE IS YOUR PAIN NOW? Using the appropriate symbols, mark all of the areas on your body where you feel the sensations described below PAIN x x x x BURNING TINGLING NUMBNESS o o o o RIGHT LEFT LEFT RIGHT FRONT BACK My number one problem is: back/neck pain arm/leg pain numbness/tingling weakness
4 PAST MEDICAL HISTORY: (check all that apply) None Apply Downs syndrome Diabetes mellitus Heart murmur Muscular dystrophy Bleeding/platelet disorder Abnormal heartbeat Neurofibromatosis Cerebral palsy Thyroid problems Rheumatoid arthritis Hepatitis (A, B, or C) Rickets Seizures Asthma Lead poisoning Spina bifida or Myelodysplasia AD/HD Kidney problems Genetic syndrome or chromosome disorder HIV/AIDS Other: Are all immunizations up to date? No Yes Birth History: Premature Full Term Vaginal delivery C section Breech Birth weight: lbs oz Please explain any birth complications: Developmental History: Check here if the patient/your child has had no developmental delays Did your child have any delays in the following: Rolling over Sitting independently Standing independently Walking holding on to furniture Walking independently Other: Please explain any checked above: Menstrual History: N/A, child is male Age at first menstrual period: Date of last menstrual period: Is there any chance that the patient could be pregnant? No Yes (**Please let x ray tech know**) PAST SURGICAL HISTORY: No prior surgery Operation Date Surgeon/Hospital Has the patient/your child ever had general anesthesia? No Yes If yes, any problems related to this? No Yes Please explain any problems related to general anesthesia: MEDICATIONS: (prescribed and over the counter) Name of Medication Dose Reason
5 ALLERGIES: Name of Medication None Reaction (rash, swelling, upset stomach, etc) Are you allergic to: Latex Nickel SOCIAL HISTORY: Grade level in school: School attended: Child s parents/guardians are: Married Divorced Separated Not Married Child lives with: Sports played: Number of brothers/sisters: Is there smoking in the house? Does the patient smoke? No Yes, number of packs per day: Prior smoker Does the patient drink alcohol? No Yes, how much/how often? Any illegal drug use? No Yes Who is the patient s primary care physician? Address: FAMILY HISTORY: (check all that apply) No significant family history Scoliosis Diabetes Bleeding problems Heart disease Low back pain Perthes disease Arthritis Cancer Round back Hip problems High blood pressure Vascular problems Other (please list): REVIEW OF SYSTEMS (check all that apply within the last 30 days): None Fever Sleep apnea (snoring) Nausea Chills Cough Vomiting Weight loss Trouble swallowing Diarrhea Weight gain Seizures Constipation Glasses/contacts Palpitations Skin rashes Vision changes Seasonal allergies Gastric reflux Urinary tract infection Food allergies ADHD Hearing loss Ear pain Other: I certify that the above is correct and complete to the best of my knowledge. Patient s Signature: Physician s Signature:
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C ADULT SPINE HISTORY For Office Use Only: HR: BP: / Name of Patient: Date: Date of Birth: Age: Height: ft in Weight: lbs Form
Today s Date: Date of Birth: Age: Height: Weight: Who Referred: If not referred, how did you choose this office? Why are you seeing the doctor today?
Name: Today s Date: Date of Birth: Age: Height: Weight: PCP: Who Referred: If not referred, how did you choose this office? Why are you seeing the doctor today? Please list major complaint(s) and describe
*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -SPINE Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
NEW SPINE PATIENT QUESTIONNAIRE
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Providence Neurosurgery PATIENT INFORMATION SHEET
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Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
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Name: Sex: Male Female. Date of Birth: Occupation: Is this an accident or work related injury?
Name: Sex: Male Female Date of Birth: Occupation: Is this a 2 nd opinion? Yes No Is this an accident or work related injury? Please list: Family MD: Referring MD: Address: Address: Phone: Phone: Fax: Fax:
Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?
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New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
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Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
Name: Age: Date: Accompanied by Relationship E-mail: @ MEDICAL BACKGROUND INFORMATION Please name the professionals that you have seen for this condition: Name Specialty Town Phone Who is your primary
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Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
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
Pain Drawing. Name: Today s Date: How were you referred to the office: Visual Analog Scale
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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.
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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Date: IDENTIFICATION: WESTERN NEUROSURGICAL CLINIC MEDICAL EVALUATION QUESTIONNAIRE Name: Date of Birth Age: Social Security No.: Driver's Lic.# Occupation: Employer: ******************************************************************************
HEALTH HISTORY QUESTIONNAIRE
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McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please