Family/Primary Doctor: Emergency Contact: Name Phone: Phone: Who referred you to our office? Who else have you seen for this condition? INSTRUCTIONS: Please provide the following information, in detail. This information is required for billing purposes. Failure to provide this information may result in your insurance company denying payment. Sex: Height: Weight: Dominant Hand: Right Left What are you seeing us for? What date did this start/happen? Is this an injury related to a : (circle one) Work accident? Yes / No Military accident? Yes / No Auto accident? Yes / No Other? Yes / No (Please Explain) IF YOU SAID YES to any of the above, please complete the following: Where were you when this injury happened? (What specific location, i.e. in house, store, parking lot) What were you doing at the time of the injury? (What specific activity, i.e. walking through door) What caused the injury? (i.e. struck nose on door, fell struck knee on asphalt) Describe How your pain started Describe location of pain FC12 1 of 3
Pain worse with Sneezing Coughing Standing minutes Walking distance Do your legs feel Tired Weak Heavy Describe the pain Sharp, knife-like Shock Burning Dull Ache Rate your pain between 1 and 10 (10 being the worst) Pain is usually (1-10) At its worst (1-10) Back Neck Leg Arms Is the pain Constant or Intermittent With Activity Does this pain Keep you awake at night Wake you out of a sound sleep Is pain resolved with sitting yes no Is pain improved with leaning forward supported (shopping cart) yes no Do you have any loss of Bladder Function Bowel Function Have you notice: Clumsy feeling legs Clumsy hands Dropping items Worsening handwriting Difficulty with buttoning buttons Have you had any of the following treatments Acupuncture Traction Heat Therapy Chiropractic Treatment Osteopathic Treatment Physical Therapy Tens (Electrical Stimulation) Psychotherapy / Psychiatric Steroid Injections List ALL previous surgeries Past Medical History / Conditions Allergies Physician Prescribed Medications Over the Counter Drugs / Herbs FC12 2 of 3
Family History: Back Pain Cancer Heart Attack Scoliosis High Blood Pressure Diabetes Stroke Does back pain run in the family yes no Does neck pain run in the family yes no Social History: Occupation/Retired Occupation: Retired: Marital Status M S D W Number of children Tobacco Use Packs/Day Quit when Alcohol / week Recreational Drug Use: Do you have any of the following: Decreased Hearing Irregular Pulse Cancer Ringing in Ears Heart Attack Diabetes Ear Infections - Frequent Fainting Spells Convulsions Dizzy Spells Swollen Ankles Stroke Failing Vision Leg Pain When Walking Psoriasis / Eczema Double or Blurred Vision Varicose Veins / Phlebitis Depression Nose Bleeds - Frequent Loss of Appetite - Recent Memory Loss Sinus Trouble Indigestion or Heartburn Phobias Sore Throat - Frequent Bloody or Tarry Stools Mental Illness Pneumonia / Pleurisy Hemorrhoids Headaches - Frequent Bronchitis / Chronic Cough Jaundice / Hepatitis Tuberculosis Asthma / Wheezing Urinary Infections - Frequent Glaucoma Short of Breath Kidney Stones / Disease Slow Healer On Exertion Lying Flat Chest Pain High Blood Pressure Heart Murmur Palpitations Venereal / Sexually Transmitted Disease History of Lyme's Disease Chronic Fatigue Weight Loss - Recent Anemia Bleed Easily FC12 3 of 3
NAME: DATE: MARK ON THIS LINE HOW BAD YOUR PAIN IS NOW NO PAIN (0) (10) WORSE PAIN 1. Mark all the areas where sensation is felt on your body using the symbols to the right. 2. Shade all affected areas of radiation. 3. Draw in your face. USING THE DIAGRAMS ABOVE DESCRIBE WHERE YOUR PAIN IS NOW 4. With an X, mark where your pain is worse now. v v v ACHING = = = NUMBING o o o PINS & NEEDLES x x x BURNING / / / STABBING FC16
Patient Name DOB Visit Type: preop 6 weeks 3 months 6 months 12 months 24 months other / annual Section 1 - Pain Intensity I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the moment Section 2 - Personal Care I can look after myself normally without causing extra pain I can look after myself normally, but it causes extra pain It is painful to look after myself, and I am slow and careful I need some help but manage most of my personal care I need help every day in most aspects of self care I do not get dressed, wash with difficulty and stay in bed Section 3 Lifting I can lift heavy weights without causing extra pain I can lift heavy weights, but it gives me extra pain Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned (e.g., on a table) Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned I can lift only very light weights I cannot lift or carry anything at all Section 4 Reading I can read as much as I want with no pain in my neck I can read as much as I want with slight pain in my neck I can read as much as I want with moderate pain in my neck I can't read as much as I want because of moderate pain in my neck I can't read as much as I want because of severe pain in my neck I can't read at all. Section 5 Headaches I have no headaches at all I have slight headaches which come infrequently I have moderate headaches which come infrequently I have moderate headaches which come frequently I have severe headaches which come frequently I have headaches almost all the time OSWESTRY NECK DISABILITY INDEX Instructions: This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage everyday life. Please answer every section and mark the ONE answer that applies to you. We realize that you may consider that two of the statements in any one section relate to you, but please mark the one which most closely describes your problem. Section 6 Concentration I can concentrate fully when I want with no difficulty I can concentrate fully when I want with slight difficulty. I have a fair degree of difficulty concentrating when I want I have a lot of difficulty concentrating when I want I have a great deal of difficulty concentrating when I want I cannot concentrate at all. Section 7 Work I can do as much work as I want to I can only do my usual work, but no more I can do most of my usual work, but no more I cannot do my usual work I can hardly do any work at all I cannot do any work at all Section 8 Driving I can drive my car without any neck pain. I can drive as long as I want with slight pain in my neck I can drive as long as I want with moderate pain in my neck I cannot drive as long as I want because of moderate pain in my neck I can hardly drive at all because of severe pain in my neck I cannot drive my car at all Section 9 Sleeping I have no trouble sleeping. My sleep is slightly disturbed (less than 1 hour sleepless) My sleep is mildly disturbed (1-2 hrs sleepless) My sleep is moderately disturbed (2-3 hrs sleepless) My sleep is greatly disturbed (3-5 hrs sleepless) My sleep is completely disturbed (5-7 hrs sleepless) Section 10 Recreation I am able to engage in all of my recreational activities with no neck pain at all I am able to engage in all of my recreational activities with some pain in my neck I am able to engage in most, but not all of my recreational activities because of pain in my neck I am able to engage in few of my recreational activities because of pain in my neck I can hardly do any recreational activities because of pain in my neck I cannot do any recreational activities at all FC15
OSWESTRY BACK DISABILITY INDEX Patient Name DOB Visit Type: preop 6 weeks 3 months 6 months 12 months 24 months other / annual Instructions: This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage everyday life. Please answer every section and mark the ONE answer that applies to you. We realize that you may consider that two of the statements in any one section relate to you, but please mark the one which most closely describes your problem. Section 1 - Pain Intensity Section 6 Standing 0 I have no pain at the moment 0 I can stand as long as I want without extra pain 1 The pain is very mild at the moment 1 I can stand as long as I want but it gives me extra pain 2 The pain is moderate at the moment 2 Pain prevents me from standing more than 1 hour 3 The pain is fairly severe at the moment 3 Pain prevents me from standing more than 30 minutes 4 The pain is very severe at the moment 4 Pain prevents me from standing more than 10 minutes 5 The pain is the worst imaginable at the moment 5 Pain prevents me from standing at all Section 2 - Personal Care Section 7 Sleeping 0 I can look after myself normally without causing extra pain 0 Pain does not prevent me from sleeping well 1 I can look after myself normally, but it causes extra pain 1 I sleep well only by using pain medication 2 It is painful to look after myself, and I am slow and careful 2 Even when I take pain medication I have less 3 I need some help but manage most of my personal care than 6 hours sleep 4 I need help every day in most aspects of self care 3 Even when I take pain medication I have less 5 I do not get dressed, wash with difficulty and stay in bed than 4 hours sleep Section 3 Lifting 4 Even when I take pain medication I have less 0 I can lift heavy weights without causing extra pain than 2 hours sleep 1 I can lift heavy weights, but it gives me extra pain 5 Pain prevents me from sleeping at all 2 Pain prevents me from lifting heavy weights off the floor Section 8 Sex Life (if applicable) but I can manage if they are conveniently positioned 0 My sex life is normal and causes no extra pain (e.g., on a table) 1 My sex life is normal but it causes extra pain 3 Pain prevents me from lifting heavy weights, but I 2 My sex life is nearly normal but is very painful can manage light to medium weights if they are 3 My sex life is severely restricted because of pain conveniently positioned 4 My sex life is nearly absent because of pain 4 I can lift only very light weights 5 Pain prevents any sex life at all 5 I cannot lift or carry anything at all Section 9 Social Life Section 4 Walking 0 My social life is normal and gives me no extra pain 0 Pain does not prevent me from walking any distance 1 My social life is normal but increases the degree of pain 1 Pain prevents me from walking more than 1 mile 2 Pain has no significant effect on my social life apart from 2 Pain prevents me from walking more than 1/2 mile limiting my more energetic interests (e.g., dancing, etc.) 3 Pain prevents me from walking more than 1/4 mile 3 Pain has restricted my social life and I do not go out 4 I can only walk using a crane or crutches as often 5 I am in bed most of the time and have to crawl to 4 Pain has restricted my social life to my home the toilet 5 I have no social life because of pain Section 5 Sitting Section 10 Traveling 0 I can sit in a chair as long as I like 0 I can travel anywhere without extra pain 1 I can only sit in my favorite chair as long as I like 1 I can travel anywhere but it gives me extra pain 2 Pain prevents me from sitting more than 1 hour 2 The pain is bad but I manage journeys over 2 hours 3 Pain prevents me from sitting more than 30 minutes 3 Pain restricts me to journeys of less than 1 hour 4 Pain prevents me from sitting more than 10 minutes 4 Pain restricts me to short necessary journeys under 5 Pain prevents me from sitting at all 30 minutes 5 Pain prevents me from traveling except to the doctor or hospital FC14
MODIFIED JOA 1. Motor dysfunction score of the upper extremety 0 - Inability to move hands 1 - Inability to eat w/a spoon, but able to move hands 2 - Inability to button shirt, but able to eat w/a spoon 3 - Able to button shirt w/ great difficulty 4 - Able to button shirt w/ slight difficulty 5 - No dysfuntion 2. Motor dysfunction score of the lower extremity 0 - Complete loss of motor and sensory function 1 - Sensory preservation w/o ability to move legs 2 - Able to move legs, but unable to walk 3 - Able to walk on flat floors w/a walking aid (cane or crutch) 4 - Able to walk up and/or down stairs w/ hand rail 5 - Moderate to significant lack of stability, but able to walk up and/or down stairs w/o hand rails 6 - Mild lack of stability but walks on flat ground unaided 7 - No dysfunction 3. Sensory dysfunction score of the upper extremities 0 - Complete loss of hand sensation 1 - Severe sensory loss of pain 2 - Mild sensory loss 3 - No sensory loss 4. Sphincter dysfunction score 0 - Inablity to urinate voluntarily 1 - Marked difficulty w/ urination 2 - Mild to moderate difficulty w/ urination 3 - Normal urination FC39