The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA C

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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): 0 1 2 3 4 5 6 7 8 9 10 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

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: 0 1 2 3 4 5 6 7 8 9 10 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?

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

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

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:

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