Mass General Thoracic Outlet Syndrome Program Questionnaire
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- Rosalind Howard
- 6 years ago
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1 Mass General Thoracic Outlet Syndrome Program Questionnaire Thank you for completing this form. This must be completed and returned by fax to , by or by mail to Dr. Donahue s office (address below) as soon as possible. For more information, please visit our website at: Dean M. Donahue, MD Massachusetts General Hospital Founders 7 55 Fruit Street Boston, MA Phone: Fax: We sincerely appreciate your interest in Massachusetts General Hospital. Today s Date: General Information Patient s name: Best contact phone number: address: Date of birth: / / Primary Care Physician: Address: Who referred you to Dr. Donahue? Name: Address: Do you have a Pain Management Physician? Name: Address: Do you have a Neurologist? Name: Address:
2 List any previous testing you have done (ultrasound, venogram, MRI, CT, X-Ray, EMG, etc). Please mail discs and results prior to your initial appointment. Describe how and when your symptoms developed: Date symptoms began (approximately): MM/DD/YYYY Are you experiencing symptoms on the RIGHT LEFT BOTH Are you RIGHT or LEFT handed? RIGHT LEFT Ambidextrous How did these symptoms begin? Did an event occur? Did they come on gradually or suddenly? What specific symptoms do you currently experience? Pain: If you have pain, please indicate the location below. Please rate your pain: 1 (mild) -10 (worst pain you have ever experienced), and indicate how often this occurs A (always) O (often) S (sometimes) R (rarely) Head (headache)/face Neck Shoulder Shoulder blade Upper Back Chest Axilla (armpit) Arm Hand Fingers Which fingers? Thumb 2 nd 3 rd 4 th 5 th
3 Numbness, Tingling, pins and needles : Please indicate location and how often this occurs. A (always) O (often) S (sometimes) R (rarely) Head/Face Neck Shoulder Shoulder blade Upper back Chest Axilla (armpit) Arm Hand Fingers Which fingers? Thumb 2 nd 3 rd 4 th 5 th Motor changes: Do you have muscle weakness, spasm or twitching? Please indicate the location and list activities you have difficulty with: (such as writing, computer use, lifting above shoulder height, dropping things, throwing) Arm Activity Fingers Activity Hand Activity Color and Temperature change: Please indicate if your hands, fingers get cold, hot, red, bluish, pale. Arm Hand Fingers Swelling: Please indicate if you experience swelling in the fingers, hand, arm. Arm Hand Fingers
4 Dizzy, vertigo, tinnitus: Please indicate if you ever feel dizzy or ringing in ears and what brings this on. Dizzy (room spinning) Unsteady (listing as if on a boat) Tinnitus (ringing in your ears) Other: Please list any other symptoms not otherwise mentioned. Height: Weight: Please list ALL other past or current medical problems, even if they are unrelated to TOS. Please list ALL operations that you have had and the year you had them. Please list ALL medications that you are currently taking, including doses. Please list any herbal/alternative medications or medical therapies? Do you have any allergies to medication? Please list. Are you allergic to IV Contrast? Yes No
5 Do you currently smoke? Yes No If so, how much do you smoke and for how many years? If you are a former smoker, how much did you smoke and for how many years? How often and how much alcohol do you currently drink? Do you have a history of alcoholism/alcohol or drug abuse? Family History: Please list any medical problems in your family or causes of death: Mother: Father: Brothers/Sisters: Sons/Daughters: Review of Systems Please place an X if any of the following symptoms apply to you. fatigue fever chills sweats loss of appetite weight loss dysphagia history of ulcer disease symptoms of angina palpitations cough shortness of breath with exertion asthma lightheadedness dizziness
6 history of stroke or seizure change in vision hearing voice history of diabetes or thyroid disease frequent urination Painful urination History of kidney stones arthritis weakness history of anxiety or depression bruising bleeding problems on blood thinning medication including aspirin Thank you for completing this form. Just as a friendly reminder, this must be completed and returned by fax to , by or by mail to Dr. Donahue s office as soon as possible. For more information, please visit our website at:
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