Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B

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Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate left or right) How long have you had these symptoms? What helps? What makes it worse? What treatments have you had? Is this Workers Compensation? Yes No Claim#: DOI: Do you have an attorney? Yes No If yes, then who? Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B No Pain 0----------1----------2----------3----------4----------5----------6----------7----------8----------9----------10 Most severe pain Pain Diagram Mark the areas on your body where you feel the described sensations. Please mark all affected areas. Use the appropriate symbols: Numbness ---- Pins/Needles 000 Burning XXX Stabbing /// Aching +++ Front right Left Back right Page 1

Review of Systems Do you currently have or have had in the past 8-12 weeks? General Yes No Cardiovascular Yes No Neurological Yes No Recent fever/chills Calf pain w/ walking Confusion Significant weight loss Chest pain Memory loss Skin Leg swelling Dizziness Bruising Irregular heartbeat Fainting Rash Gastrointestinal Headaches Eyes/Ears/Nose/Throat/Mouth Abdominal pain Balance Problems Mouth sores Blood in stools Numbness/tingling Change/blurring of vision Diarrhea Seizures Double vision Nausea Psychiatric Ear infections Vomiting Anxiety Hearing loss Genitourinary Depression Ringing in the ears Painful urination Endocrine Vertigo Blood in urine Excessive thirst Nasal congestion Incontinence Cold/heat intolerance Recent sore throat Musculoskeletal Low blood sugar Respiratory Joint pain or swelling Hormone replacement Cough (recent or chronic) Muscle pain Steroid use Shortness of breath Hematologic Excessive bleeding Past Medical History Check the medical problems you currently have or have had in the past Cancer, if so, what type? Congestive heart failure Heart disease, Cardiologist? Hypertension (high blood pressure) Heart attack Ulcers/GERD History of blood transfusions Rheumatoid arthritis Seizures/epilepsy COPD Page 2

Past medical History Continued Heart Murmur Diabetes: Insulin Oral meds Diet controlled Asthma, if yes, last hospitalization: Sleep apnea, if yes, do you use a CPAP? Hypothyroidism Yes No Depression/anxiety Blood clots (DVT/Pulmonary embolus) Kidney disease Hepatitis: A B C Stroke MRSA (Methicillin resistant staph aureus) Other: Allergies Please list all allergies, including medications, iodine and contrast. None known OR Yes, if so, please list them: Family History Please list family history. If yes, list relative, if they are living and the age at death if deceased. Problem list Relative Living? Yes No Yes No Age of death Blood clotting disorders? Cancer? What type? Diabetes? Heart disease/heart attack? Hypertension (high blood pressure) Stroke? Other? Social History Yes No History of substance abuse? If yes, describe: Do you drink alcohol? If yes, Occasional Moderate Heavy Smoke currently? If yes, packs/day for years Page 3

Social History Continued Yes No Quit smoking? If yes, how long ago did you quit? Are you married? If yes, what s your spouse s name? Employed? Full time Part time Disabled Retired Occupation? Do you have children? If yes, number of children: Student? *Pediatric patients (Ages 0-16) Grade level? Name of school/daycare attending? *Pediatric patients (0-16): Are immunizations current? Yes No Medications List ALL medications, including over the counter products, minerals, vitamins, herbal and dietary supplements. For pain medications, please include the date started and the provider that does the refills. Drug name Dose/how often Past Surgical History Please list all surgeries you have had, including the date. Circle Right or Left, if applicable. Prior joint surgeries Yes No Date Other surgeries Yes No Date Hip R L Heart surgery/heart stents Knee R L Appendectomy Shoulder R L Tonsillectomy Neck Gallbladder Back Hysterectomy Other surgeries not listed, type and date: Page 4

Diagnostic Studies Which of the following diagnostic tests have been done on your head/neck/back? Please indicate the date below. Yes No Date (M.D. use only) Regular Spine X-ray CT Scan MRI Scan Myelogram Discogram Bone Scan EMG Nerve Blocks Facet Blocks Conservative Care What types of conservative care have you tried? (Physical Therapy, Chiropractic, Massage Therapy) What type? Where? How long? (date range; # of visits) Did you get any relief? Are you claustrophobic? Yes No Do you have any metal in your body? Yes No Patient/Guardian s Signature: Date: Page 5

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