Spine Center New Patient Form

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Transcription:

Spine Center New Patient Form Last Name First Name Middle Name Age: Hand Dominance Right Left Definitions Gender Male Female Carefully read the following definitions Pain Levels Neck Pain Arm Pain Back Pain Leg Pain The level of pain you have had on average since your problem began Neck includes middle of neck, upper shoulders, between shoulder blades Arm includes shoulder, arm, or hand Back includes pain above the belt line across the lower back Leg includes areas below the belt line including the buttock, legs, or feet Describe your condition: In your own words, note the following: 1) What happened to you?; 2) What you feel?; 3) What caused it?; 4) How it changed over time? What was the approximate date your problem started? Have you had any of these diagnostic studies No Yes Date Xrays of injured area MRI (magnetic resonance imaging) CT (computed tomography) scan Myelogram (x-ray with dye injection) Electromyogram (EMG) Discogram Arthrogram of sonogram November 2018 Spine New Patient Form Page 1

Did your problem begin with a car accident? No Yes If yes: Were you the driver? No Yes Were you wearing a seatbelt? No Yes Did you pass out? No Yes To be sure all paperwork is filled out correctly, please check appropriate On Workman s Compensation Receiving Disability Income Legal Proceeding Pending Yes Report should be sent to Referring Physician or Family Physician Report should be sent to another party: Name and Address: Yes For a total of 100%, what % is back pain and what % is leg? % Low Back Pain % Leg Pain (i.e. 30% low back pain with 70% leg pain) + =100% For a total of 100%, what % is neck pain and what % is arm? % Neck Pain % Arm Pain (i.e. 20% neck pain with 80% arm pain) + =100% Your average level of pain 0 1 2 3 4 5 6 7 8 9 10 Less Pain Worse Pain Neck Pain Right Arm Pain Left Arm Pain Low Back Pain Right Leg Pain Left Leg Pain Your level of pain right now Describe the quality and severity of your pain? Throbbing Gnawing Splitting Shooting Hot-Burning Tiring/Exhausting Stabbing Aching Sickening Sharp Heavy Fearful Cramping Tender Punishing-Cruel November 2018 Spine New Patient Form Page 2

Using the symbols, mark the location and type of pain on the diagrams RIGHT LEFT LEFT RIGHT If you have pain into the lower leg, feet, or hands, make sure you note it Type of Sensation: Stabbing/Burning: ^ FRONT BACK Aching: X Pins and Needles: Numbness: O Do you have: No Yes Explain where Numbness in the arms/hands or legs/feet? Weakness in the arms/hands or legs/feet? Pain worse with Pain better with Morning Afternoon Evening Night Lying flat Sitting Standing Walking Bending Back Coughing/ Sneezing List the daily activities, sports, or hobbies you are having difficulty performing due to your pain Do you have: No Yes Loss of bowel control? (difficulty controlling/initiating bowel movements or incontinence) Loss of bladder control? (difficulty controlling/initiating urination or incontinence) Night pain for which you change position or get out of bed? Balance problems from leg weakness? Balance problems not from weakness but from lack of coordination? Problems handling small objects such as coins or problems buttoning your shirts? November 2018 Spine New Patient Form Page 3

Treatment history No Yes Details (If Yes) Acetaminophen (Tylenol) Non Steroidal Antiinflammatory Drugs (NSAIDS) or COXinhibitors (e.g. Advil) Opiods (ie Vicodin, Percocet, Morphine) Neuropathic pain meds (Gabapentin, Lyrica) Interventional pain procedures (Epidurals, nerve or joint injections, implants) Physical Therapy Acupuncture Chiropractor Physiatrist or Pain Specialist Pain Psychologist Other Pain Physician How many: Date of last injection: How long: Medical history (ie: High blood pressure, asthma, high cholesterol, heart problems, diabetes, etc) I have no medical problems Made my pain: Better No Change Worse Do you have history of cancer? No Yes Details (If Yes) Type: Prior treatment: Surgical history (i.e.:tonsillectomy, hip replacement, heart surgery, etc) Date of Surgery Surgery (Specify Right or Left side if relevant) I have not had surgery in the past November 2018 Spine New Patient Form Page 4

Mental Health History Psychiatrist I have not seen a mental health expert in the past No Yes Name Practice Location Psychologist List ALL medications, vitamins, and supplements you are currently taking. (May attach list of medications) I currently take no medications Allergic reactions including medicines, iodine, intravenous dye, latex, shellfish, etc. Medication/Substance Allergic Reaction I have no allergies Occupational/Social history What is your occupation? I am currently retired No Yes Details (If Yes) Are you out of work due to your spinal condition? How long have you been out of work? Do you have a workman s compensation claim? Date of work injury: Do you smoke cigarettes? Do you smoke a pipe or cigars? Do you dip snuff or chew tobacco? Do drink caffeine? Do drink alcohol? Do you use any street drugs? Have you been diagnosed with a substance abuse problem How many packs per day? For how many years? How often? How often? How many cups per day? How many drinks per week? Which drugs and how often? Which substance? Who do you live with? Family history of disease I have no family history of disease Relationship Disease Relationship Disease November 2018 Spine New Patient Form Page 5

Review of systems General Eye,Ear Nose,Throat Musculoskeletal Psychiatric Fever or Chills Difficulty swallowing Joint pains Anxiety Dizziness Hearing loss Muscle aches Depression Fainting spells Hoarseness Ankylosing spondylitis Psychiatric hospitalization Fatigue Nose bleeds Weak bones Panic attacks Frequent headaches Ringing in ears Rheumatoid arthritis Suicidal thoughts Insomnia Sinus problems Osteoarthritis Psychiatric drugs Sweats Blurry vision Bone cancer Memory loss Weight changes Poor vision Bone infections Other: Other: Other: Other: MEN only Cardiovascular Gastrointestinal Genitourinary Breast lumps Ankle swelling Poor appetite Bladder control Enlarged prostate Chest pains Bowel changes Blood in urine Erectile dysfunction Enlarged heart Constipation Frequent urination Penis discharge Heart attack Diarrhea Kidney stones Prostate cancer Heart murmur Excessive thirst Painful urination Other: Heart palpitations Heartburn Urgent urination WOMEN only High blood pressure Nausea Weak stream Abnormal pap smear Shortness of breath Rectal bleeding Other: Breast lumps Irregular heartbeat Stomach pain Neurological Vaginal discharge Prolonged bleeding Ulcers Loss of motor control Severe menstrual pain History of blood clots Vomiting Weakness Hot flashes Other: Other: Paralysis Other: Endocrine Skin Poor balance Date of last period: Blood sugar problem Bruise easily Seizures Age periods began: Use of steroids Foot ulcers Speech difficulties Age of menopause: Over active thyroid Rashes Tremors Are you pregnant? Under active thyroid Sores that won t heal Muscle wasting # of pregnancies? Other: Other: Other: # of live births? This form is used to gather information so that my doctor can maximize the time used to examine me and answer my questions about my condition and treatment options. I certify that the following information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may make in the completion of this form. Patient Signature (Date) Physician Signature (Date) Office Use Only Height Weight BP / Pulse November 2018 Spine New Patient Form Page 6

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