DEPARTMENT OF NEUROSURGERY Spine Center New Patient Intake Form

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DEPARTMENT OF NEUROSURGERY Spine Center New Patient Intake Form Today's date: Your name: Date of birth: Email address: CHIEF COMPLAINT What is the main reason that you are seeking medical attention? Please briefly describe how your problem started: DESCRIBE YOUR PAIN Has your pain been improving, worsening, or staying the same? How long have you had your current pain? Have you had pain like this before? Please describe each type of pain that you experience: Please rate your pain when it is at its worst (bad day) with an X: Achy Dull Throbbing Stabbing Burning Numbness Tingling Cramping Mark on the scale below, with 0 being no pain and 10 being the worst imaginable. 0 Pain How long can you sit? How long can you stand? How long can you walk? Do you have weakness in arm(s)? Do you have weakness in leg(s)? WHAT TREATMENTS HAVE YOU TRIED FOR THIS CONDITION? Chiropractic Was it helpful? Acupuncture Was it helpful? Other alternative therapy? What kind and was it helpful? Physical therapy? Was it helpful? Injections? When? Was it helpful? Which area of the body and when? 10 Worst Pain Page 1

PAIN DIAGRAM Using the appropriate symbol, draw on the body diagram areas of stabbing or shooting pain with an X, areas of burning pain with a +, and areas of numbness with an O: PAST MEDICAL HISTORY: Please check any of the following difficulties which you now have now or in the past: Asthma When Anxiety When COPD When Depression When Emphysema When Substance Abuse When Tuberculosis When Arthritis When CHF When Nerve/muscle disease When Heart attack When Osteoporosis When Heart murmur When Cataracts When Hypertension When Glaucoma When Kidney Disease When GERD When Stroke When Ulcers When Anemia When Allergies When Blood transfusion When Diabetes Mellitus When Clotting disorder When HIV/AIDS When Sickle cell anemia When Thyroid disease When Meningitis When Cancer When Seizures When What kind Other relevant medical history Page 2

PAST SURGICAL HISTORY: Please list all surgeries and please bring operative reports of any spine surgeries to your appointment: Type of surgery/ side Date MEDICATIONS: Please list all of your current medications, including over the counter medications: Name Dosage Number of times daily Are you taking any blood thinners? (Coumadin, Warfarin, Plavix, Aspirin, etc) Please list, including dosage: ALLERGIES Please list allergies and your reactions to them, particularly medications: EMPLOYMENT Are you currently working? If yes, what is your occupation/title? Is there current or upcoming litigation (lawsuit)? Is there a current or upcoming worker's compensation hearing? SOCIAL HISTORY: Single Married Domestic Partner Divorced Widowed Highest level of education: Elementary High School College Graduate/Professional Degree Do you have children? Do you currently smoke tobacco? If yes, how many? If yes, how much daily? Prior tobacco use? If yes, how much? Do you use drugs? If yes, which and how often? Do you use alcohol? If yes, how much a day? Prior alcohol or drug abuse? If yes, which and how much? Do you exercise? If yes, what and how often? Page 3

FAMILY HISTORY Condition type/affected relative Condition type/affected relative Cancer Heart Disease Glioma High Cholesterol Aneurysms Hypertension Other conditions Diabetes Bleeding/Clotting Problems REVIEW OF SYSTEMS: Please check any of the following difficulties which you now have, or which you have experienced over the past six months: Constitutional: Fever When Endocrine: Excessive urination When Weight loss or gain When Excessive thirst When Excessive fatigue When Genitourinary: Eyes: Urinary tract infections When Blurry vision When Painful urination When Double vision When Blood in your urine When Ear, se, Throat: Incontinence When Hearing difficulty When Musculoskeletal: Ear pain/infection When Broken bones When Ringing in ears When Arm or leg weakness When se bleeds When Arm or leg pain When Nasal drainage/congestion When Joint pain or swelling When Sore or hoarse throat When Neurological: Balance problems When Fainting spells When Heart Seizure When Chest pain or angina When Memory loss When High blood pressure When Disorientation When Heart trouble When High cholesterol When Lungs Shortness of breath When Coughing/wheezing When Gastrointestinal Nausea/vomiting When Heartburn Diarrhea Ulcers or gastritis When When When Psychiatric: Anxiety When Depression When Hematologic/Lymphatic: Bruising When Hemophilia When Jaundice When HEALTH CARE PROXY Do you have a Health Care Proxy currently? If no, and you would like more information, please see our receptionist. Page 4

YOUR HEALTH STATE: To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today. CURRENT STATUS Please check one box in each group below that best describes your own health today: Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself Usual Activities I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed Your own health state today The information on this form is accurate to the best of my knowledge: Patient Signature: Date Completed: I have reviewed the above information with the patient: Physician Signature: Date Reviewed: Clinical ID #: Page 5

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