FAIRYLAND HOSPITAL 123 Santa s Row, South Pole
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1 FAIRYLAND HOSPITAL 123 Santa s Row, South Pole info@fairylandhospital.com Patient Name: Trevor ABRAHAMS MRN: Patient ID: Date of Birth: 05/04/1966 Visit Date: 05/06/2012 Surgeon: Dr John Lincoln Referring Physician: Dr Mary Smith Hospital: Fairyland Hospital Insurance: Blue Cross Questionnaires completed online on: 06/12/2012 Chief Complaint: Lower back or leg symptoms History of Present Illness: Trevor is a 47 year old male presenting with lower back pain reporting 2 prior episodes. The onset was sudden, it started 7-12 months ago and was caused by sporting injury. He describes the pain as spastic/crampy and it is made worse by lying down on belly. On the VAS pain scale his back pain is 2 out of 10 with the pain being relieved by bending backwards. The pain is 90 % in the back vs 10 % in the leg. Pain is reported in the left leg which started 7-12 months ago There have been 2 previous episodes of this pain,caused by sporting injury and is described as spastic/crampy The onset was after trauma or accident, it is made worse by Sports and is getting better. The pain is relieved by changing position. ADL and work He responded that the pain affected work and daily activities a little bit, and no to being asked if the pain wakes him at night. His job status is full-time, some limitations. He is on workers compensation, litigation is pending. Neurological symptoms There is numbness/tingling felt in the lower leg.other symptoms reported are weakness in arms.the weakness has been felt for 6-12 weeks, crutches needed to walk.the symptoms have improved since they started. He states that the overall quality of life has been minimally affected. He can walk mins before the pain becomes too severe. Interventions/surgery to date He has consulted another Dr. Prior surgery details - previous back surgery which was < 6 weeks ago - had no complications. Back surgery was discectomy Tests done for current problem are: Bone scan Patient stated that they had also had other tests which were: Went to see an Osteopath, it didnt help. Medications Medications taken regularly are Crestor Analgesics taken are Non-narcotics (Tylenol, Tramadol, Panadol) the effect being described as a little 1
2 Other treatment tried Tried Muscle Relaxer: Yes which helped some Tried Facet Injections: Yes which helped a lot General History He is left handed,weighs kgs and is cms tall. He has lost weight intentionally in the past year, the amount being 6.00 (kgs) He exercises 5 days a week, main exercise/s being Biking, Walking Employment status Trevor is employed,claims to be very satisfied with job which mainly entails frequently lifting objects >20lbs/10kgs. Medical History He reports experiencing dizziness in the past 6 months, Medical conditions reported are Bleeding or clotting disorder, Asthma. Other details reported by patient: My asthma is very bad He has a history of cancer of Colon/Bowel. He has previous mental health/psychiatric history and describes mood as normal He has been to ER in past 12 months, 1-2 months ago and the ER visit not spine related Hospitalized in past 12 months for Asthma He has had previous non-spine related surgery, details of which are Removal of appendix The surgery had complications which were bleeding Family details He is married with 2 children Family history Family history of back/neck problems with sister being the affected member. Father has had previous spine surgery Allergies- Medications He has medication allergies to Heparin No penicillin allergy, No sulphur allergy, Other antibiotic allergies, NSAIDS allergies, No narcotic allergies Other Allergies No iodine/shellfish allergies, No latex allergy, Unaware of tape/dressing material allergies, Unaware of metal allergies, Forms keloid/bad scars Alcohol/smoking/drug history Smokes, smokes ½ -1 packs a day,is willing to quit Doesn't dip/chew tobacco He drinks alcohol, 4-6 drinks per week. Has not been treated for a drinking problem and has been treated for a drug problem Vital signs Weight:89.00 Height:
3 BMI:30 Pulse:90 Blood Pressure:/ Physical Examination Comorbidities Cardiac/respiratory Comorbidities: Asthma, Seasonal Allergies Constitutional Heart Rate: 90 BP-Systolic: 150 BP-Diastolic: 90 Height in cms: Weight in kgs: Height/Weight source: Reported Nutrition status: Normal BMI: 30 Appearance: Conversant, Well Dressed Allergy/immunology Drug Allergies: Reported Tape Allergies: Reported Environmental Allergies: Denied Mental Mood: Depressed Mental health status is improving, Orientation: Alert and oriented x 3 (person, place, time) Eyes: 1(no eye opening) ENT External inspection: normal,hearing - normal. Eyes Conjunctiva is normal, normal droop. Skin Skin Appearance: normal Palpation: Normal Observations: Normal Temperature Head Cranial Nerves intact to examination: Yes Head status: Normocephalic Respiratory/Chest Respiratory/Chest- no cough, no shortness of breath, normal palpation Abdomen/GI/GU 3
4 Abdomen: nontender Cardiovascular Well perfused extremities Carotid present Cervical Spine Skin normal Paravertebral muscle spasm: None Tenderness to palpation: None Range of Motion is unrestricted Movement is painless Patient cooperation with exam: normal Lumbar Spine Examination of the lumbar spine was unremarkable, with no obvious abnormalities. The following tests were performed: Skin normal Paravertebral muscle spasm: Bilateral Tenderness to palpation: Right Crepitus: Yes Step-off: yes Range of Motion is unrestricted,movement is painful/pain limited Coronal Balance: Neutral Sagittal Balance: Neutral Cooperation with exam: Normal Shoulder/Elbow ROM Shoulder Left: Full Elbow left: Full Signs Knee Range of Motion Left - Full Right - Full Hip ROM Left - Full Right - Limited by Stiffness Neurological Upper Extremity Exam Effort Left - Good Right - Good Give way weakness: None Tone: Normal Tone: Normal GAIT 4
5 Gait: Stable Patient Outcome scores Todays Modified Oswestry Disability score is 48 out of 100 (0 = best score) Today's VR 36 mental score is 62.05,Physical score is
CERVICAL Orthopedic Specialists of Louisiana Pierce D. Nunley, MD PERSONAL INFORMATION. Patient Name:
PERSONAL INFORMATION (Please Print or Type) Patient Name: Last First MI Registration Date: / / Birthdate: / / Age: Social Security #: - - Sex: Address: Apt. # Street Telephone Numbers: ( ) Occupation:
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
Please review the below items in preparation for your visit.
2001 Santa Monica Blvd., Suite #760W Santa Monica, CA 90404 (310) 582-7474 (Office) (310) 582-7481 (Fax) http://california.providence.org/saint-johns/services/orthopedics/ http://www.totaljoints.net/ Dear
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D. PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC Name: Age: Sex: Male Female Occupation: Job description: Date: PLEASE ANSWER THE FOLLOWING QUESTIONS: Major
Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)
Patient s Name: Date: What is the reason for your visit today? Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone #
BACK AND NECK PAIN QUESTIONNAIRE
Neurological Surgery and Spine Surgery, S.C. 1 Westbrook Corporate Center, Suite 800 Westchester, Illinois 60154 BACK AND NECK PAIN QUESTIONNAIRE Please PRINT all information CLEARLY and answer all questions
LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
Whom may we thank for referring you to this office Today s Date: PATIENT DEMOGRAPHICS? HRN: Name: Birth Date: Age: Male Female Address: City: State: Zip: E mail Address: Home Phone: Mobile Phone: Marital
Please take the time to answer all questions that apply to your problem as completely as possible. Thank You.
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
Pain Drawing. Name: Today s Date: How were you referred to the office: Visual Analog Scale
Pain Drawing Name: Today s Date: How were you referred to the office: Please be sure to fill this out as accurately as possible. This will become part of your permanent medical record and will be used
PATIENT INTAKE FORM. Name Date of Birth Age. Address Sex. Home Phone Primary Care Physician. Address Phone # Referring Physician.
PATIENT INTAKE FORM Date Name Date of Birth Age Address Sex Home Phone Primary Care Physician Address Phone # Referring Physician Address Phone # CHIEF COMPLAINT: Describe in your own words why you came
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form
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NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
PLEASE BRING COMPLETED PACKET TO APPOINTMENT ALONG WITH YOUR FILMS
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Numbness: o o o o o. Grade your overall pain. Pain Rating Scale Mosby. Worst Possible Pain. No Pain HURTS LITTLE MORE HURTS EVEN MORE
Patient Name: Original Referring Physician: Current PCP: PAIN DIAGRAM Is your condition the result of a: Work injury? YES NO Auto accident? YES NO Date of Injury: / / Please mark the areas of discomfort
LUMBAR Orthopedic Specialists of Louisiana Pierce D. Nunley, MD PERSONAL INFORMATION. Patient Name:
PERSONAL INFORMATION (Please Print or Type) Patient Name: Last First MI Registration Date: / / Birthdate: / / Age: Social Security #: - - Sex: Address: Apt. # Street Telephone Numbers: ( ) Occupation:
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
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Type of Patient and/or payment method (circle one)
Please print # Date: Last Name: First Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Email address: Date of Birth: Sex: M F Social Security #: Employer name: Occupation: (if a minor,
Spine New Patient Questionnaire Rev
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SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD
Name: Height: Birthdate: Weight: Chief Complaint: What is the reason for your appointment? (please describe why you are here) Medications: Please list ALL medications with dosages you are currently taking,
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
*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
Name Date Date of Birth Last Name First Name Middle Initial. Employment Information
Zindt Chiropractic Center 3819 S M St Workmen s Compensation Tacoma, WA 98418 Information Name Date Date of Birth Last Name First Name Middle Initial Employment Information Employer s business name (at
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
NEW PATIENT INFORMATION
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We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
DUKEMedicine. SMITH, JAMES MRN: D DOB: 2/6/1993, Sex: M Adm: 2/15/2016, D/C: 2/15/2016
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The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C
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/ / Last Name First Name Middle Name MO / DA / YEAR Date of Birth ( ) ONSET: When did your most recent episode of pain begin? Lifting Pushing Pulling
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NAME OF PATIENT: STREET ADDRESS: CITY: STATE: ZIP: SEX: Male Female AGE: BIRTHDATE: MARITAL STATUS: PATIENT EMPLOYED BY: BUSINESS ADDRESS:
DATE: HOME PHONE: NAME OF PATIENT: (Last name) (First name) (Middle) RESPONSIBLE PARTY (if a minor): STREET ADDRESS: CITY: STATE: ZIP: SEX: Male Female AGE: BIRTHDATE: MARITAL STATUS: PATIENT EMPLOYED
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Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
Last Name First Name MI: Address City State Zip. Referring Provider. Employer Address. Emergency Contact Relationship Phone. ID # Group # ID # Group #
Patient Demographic o New Patient o Return Patient o Update Account #: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave
Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#
Date Name / / last first middle initial Personal Health # - Male Female Home Address City Postal Code Home Telephone # Business Telephone # Cell # E-Mail Address Best way to contact you: Home # Work #
New Patient Intake Forms. Patient Data Date. Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other. First Name Middle Initial Last Name
New Patient Intake Forms Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name I prefer to be called by Address Line City State Zip Code Home Phone ( ) -
Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should
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 PEDIATRIC SPINE HISTORY Name of Patient: For Office Use Only: HR: BP: / Date: Date of Birth: Age: Height: ft in Weight: lbs Form
Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
Please Check the appropriate box: Single Divorced Married Widowed Number of Children & Ages:
Date: Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Primary Number: Secondary Number: Mobile Number: Home Email: Work Email: Date of Birth: Age: Gender: M F
Pharmacy Name/Location/Phone number:
Pharmacy Name/Location/Phone number: Family Physician Name: Phone: Address: Referring Physician Name: Phone: Address: First Emergency Contact: Relationship: Home/cell phone: Work phone: Second Emergency
Medical History Questionnaire
Date Medical History Questionnaire Name DOB Reason for visit When did symptoms first appear Is the condition getting worse? Please rate your pain 0 1 2 3 4 5 6 7 8 9 10 No Pain Extreme Pain Please circle
PRACTICE NAME NEW PATIENT MEDICAL HISTORY FORM. Chief Complaint. History of Present Illness
PRACTICE NAME NEW PATIENT MEDICAL HISTORY FORM Height: Weight: Race: African American Asian Caucasian Native American/Alaskan Pacific Islander Other Unknown Decline to Answer Ethnicity: Hispanic Non-Hispanic