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

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Transcription:

The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C ADULT SPINE HISTORY For Office Use Only: HR: BP: / Name of Patient: 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, Flatback Syndrome, Spondylolithesis, etc) Neck Pain Arm: Pain Numbness Weakness Back Pain Leg: Pain Numbness Weakness Other: Please describe your problem: How long has the pain/problem been present? 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 Any numbness or tingling? No Yes, where? Does the patient have weakness in his/her arms or legs? No 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 far can you walk? (number of blocks) Are you right or left handed? What treatments have you tried? (check all that apply) No previous treatment Neck Back Neck Back Physical therapy/exercise Anti-Inflammatory medications Massage/Ultrasound Narcotic medication Chiropractic treatment TENS unit Acupuncture Braces Epidural steroid injections, times, which relieved the pain for how long? Trigger point injections, times, which relieved the pain for how long? Surgery, describe: 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 Because of this problem, have you filed or do you plan to file a lawsuit? Yes No

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: X-rays MRI CT scan Bone scan Other Results Date Location/Facility Is there any other information that the doctor should be aware of? FOR PATIENTS WITH SPINAL DEFORMITY/BACK CURVATURE: How was your spinal deformity discovered? Do you know your present curve measurement(s)? Reasons for seeking treatment at this time: progressive deformity pain can t stand straight don t like the appearance of back/waistline other: FOR WORKMAN S COMPENSATION PATIENTS: Date of injury/incident: Have you been put on light duty? No Yes Describe the injury/incident: Have you been out of work due to this injury? No Yes, last date worked: Name of the company that you work(ed) for when the injury occurred? What was your job title? How many years did you work there? Have you had any prior workman s compensation injuries in the past? No Yes, describe below: Prior to this injury, have you ever seen a physician/chiropractor for neck or back pain? No Yes Describe: Any history of a previous motor vehicle accident? No Yes

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 Heart attack (MI) Asthma Rheumatoid arthritis Depression Heart failure (CHF) Tuberculosis Osteoarthritis ADHD Abnormal heart beat Emphysema Downs syndrome Seizures High blood pressure (HTN) Thyroid problems Osteoporosis Migraine Stroke (CVA) Stomach ulcers Cerebral palsy Cirrhosis Blood clots in leg (DVT) Gastric reflux Hepatitis (A, B, or C) Gout Blood clot in lung (PE) Hiatal hernia Neurofibromatosis Spina bifida Poor circulation (PVD) Kidney failure (CKD) Bleeding/platelet disorder HIV/AIDS High cholesterol Kidney stones Anemia Cancer, type/treatment: Diabetes mellitus, year diagnosed: Neuropathy: Hands or Feet Diabetes is currently controlled with: insulin oral medications diet Other: Menstrual History: N/A, patient is male Date of last menstrual period: Is there any chance that you could be pregnant? Menopause No Yes (**Please let x-ray tech know**) PAST SURGICAL HISTORY: No prior surgery Operation Date Surgeon/Hospital Have you ever had general anesthesia? No Yes If yes, any problems related to this? No Yes Please explain any problems related to general anesthesia: Any hospitalizations besides above surgeries? 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: Do you currently smoke? No Yes, how many packs per day? For how many years? Have you quit smoking? If yes, when? How many years did you smoke? How many packs per day did you previously smoke? Other forms of tobacco? Alcohol Use: None Rare Social Frequently (more than twice a week) Alcoholic Recovering alcoholic Illegal Drug Use: None In the past Currently Types of drugs: Work Status: Working Homemaker Disabled On leave Unemployed Retired Student Occupation: Marital Status: Single Married Divorced Separated Widowed Children: No Yes, how many? Do you live alone? If no, who lives with you? Who is your primary care physician? Address: FAMILY HISTORY: (check all that apply) No significant family history Scoliosis Diabetes Arthritis Bleeding problems Heart problems Cancer High blood pressure Stroke Seizure Alcoholism Lung problems Gout Mental illness Blood clots (legs or lungs) Other (please list): REVIEW OF SYSTEMS (check all that apply within the last 30 days): None within past 30 days Fever Sleep apnea (snoring) Nausea Chest pain Chills Cough Vomiting Palpitations Dizziness Trouble swallowing Diarrhea Shortness of breath Headache Seizures Constipation Memory loss Glasses/contacts Anxiety Skin rashes Weight gain Incontinence Seasonal allergies Gastric reflux Weight loss Erectile difficulties Food allergies Urinary difficulty Vision changes 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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