ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address

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ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to? Employer -if so name, address and phone Employer address PATIENT HEALTH HISTORY CHIEF COMPLAINT: What specifically brings you to see the physician today? HISTORY OF PRESENT ILLNESS: 1. Describe present symptoms: Location, severity, onset and duration. If you have pain or numbness or other sensory changes, please mark the areas on the next page and answer the following questions that apply to you: O Morning O Later in the day O During the night O Always the same What activities worsen your symptoms? O Arm overhead O Lifting O Riding and/or driving a car O Sneezing O Straining bowels O Climbing stairs O Sitting O Movement of the neck/back O Standing O Walking O Coughing O Other Have changes occurred in your bladder, bowel, or sexual function? O YES O NO If YES, please describe: 2. Describe how it happened or what you think caused it: 3. When did the symptoms begin? Month and date. 4. If injury / accident related, date of injury / accident: 5. Is this injury related to work? O YES O NO O UNCERTAIN 6. Have you filed a Workers Compensation claim? O YES O NO 7. Is this injury related to an auto accident? O YES O NO 8. Is a lawsuit in progress or being planned? O YES O NO 9. Please list tests you have already had: O MRI O CT O Myelogram O Discogram O Regular Spine X-rays O Bone Scan O EMG O Angiogram O Other 10. Please list all other physicians and chiropractors who you have seen for this problem and treatments that have been performed: DATE PHYSICIAN TREATMENTS LOCATION 11. Have you been in physical therapy? O YES O NO DATE FREQUENCY DATE ENDS LOCATION 12. What (other) treatments have you already had (injections, acupuncture, previous spinal surgery)?

2 of 5 SENSATION DRAWING Where is your pain now? Mark the areas on your body where you feel the described sensations. Use the appropriate symbol. Mark the areas of radiation. Include all affected areas. Face pain Neck pain Arm pain Back pain Leg pain Total Score= % % % % % = 100% SYMPTOM= Ache Numbness Pins / Needles Burning Radiating Pain SYMBOL= ^^^^^^^^ 000000000 ========== xxxxxxx //////////////////// How bad is your pain? On a scale of 0 to 10 (0 = no pain, 5 = moderate, 10 = worst pain) At its very worst 0 1 2 3 4 5 6 7 8 9 10 Now 0 1 2 3 4 5 6 7 8 9 10 Overall, is your pain generally: O Improving O Same O WORSENING?

3 of 5 PAST MEDICAL HISTORY. List significant illnesses or hospital stays without surgery. Are you a diabetic? O YES O NO SURGERY AND HOSPITALIZATION HISTORY. List ALL previous surgeries and hospitalization, include dates and physicians names. If you are a female are you pregnant? O YES O NO How many pregnancies? How many births? FAMILY HISTORY: Current Age or Age at Death Health Problems or Cause of Death FATHER: O Alive O Deceased MOTHER: O Alive O Deceased Number Ages Serious Illnesses Number Deceased / Cause Sisters: Brothers: Daughters: Sons: Spouse: Do you know of any blood relative who had had the following illnesses: If yes, check all that apply and provide relationship to patient? O Aneurysm O Chiari Malformation O Lung Disease O Brain Hemorrhage O Diabetes O Seizures O Brain Tumor O Heart Disease O Stroke O Cancer O Spinal Disease

4 of 5 NEUROSURGERY SERVICES: CURRENT MEDICATIONS. Please complete the medication list below with the medications you are currently taking. If you have difficulty completing this form, please bring your medication with you to your appointment. Include name, dose, and frequency. Medication: Dose How often you take it? ALLERGIES. Include medications, foods, tapes, latex. Include what adverse reaction you experience. Do you wear a prosthesis, pacemaker, or metal implant? O YES O NO If yes, please specify. Are you claustrophobic (having fears or anxiety in a confined environment, i.e. MRI)? O YES O NO SOCIAL HISTORY AND HABITS: 1. O Married. O Divorced. O Single. O Widow / Widower. O Significant Other. 2. Who lives with you? 3. If you have surgery, who can help you when you go home from the hospital? 4. Do you smoke? O YES O NO If so, how much? pack per Did you ever quit? O YES O NO. IF so, when did you quit? Are you interested in assistance with quitting? O Medication O Self help 5. Are you exposed to second hand smoke? O YES O NO 6. Do you use alcohol? O YES O NO If so, how much? When did you quit? 7. Do you use and street drugs? O YES O NO If so, how frequently? Did you ever use any? 8. Are you retired? O YES O NO 9. Are you employed? O YES O NO If so, where? O Full Time O Part time O Disabled since Present and / or former occupation Describe the type of work you do (i.e. lifting, standing, sitting). How many years have you done this job? Have you lost work due to this current injury? Last date worked

5 of 5 NEUROSURGERY SERVICE REVIEW OF SYSTEMS: Please check those times that pertain to you during your lifetime. ALLERGIES Asthma Hay fever Other CARDIOVASCULAR Heart attack Heart surgery Stents High blood pressure Chest pain Difficulty breathing at night Heart Murmur Irregular heart beat Pacemaker Poor circulation Swollen legs or feet Varicose veins EARS/NOSE/THROAT Bleeding gums Difficulty swallowing Earache Hoarseness Ringing in ears Sinus problems Disease/injury Glaucoma Hearing Loss o Right o Left ENDOCRINE Diabetes Excessive hunger/ thirst Intolerance to warm room Loss of libido Multiple broken bones Rapid weight gain Rapid weight loss Spontaneous nipple discharge Thyroid problems Patient Signature: EYES Blurred vision Crossed eyes Double vision Eye infections Vision flashes or halos Eyeglasses/contacts GENERAL Chills/sweat/fever Difficulty sleeping Headache Recent fatigue Recent weight gain Recent weight loss GASTROINTESTINAL Black stools Blood in stools Chronic diarrhea Heartburn/ acid reflux Hepatitis A,B,C (circle one) Increasing constipation Liver disease Nausea Vomiting GENITOURINARY Difficulty to initiate/retention Discharge from penis/vagina Kidney Stones Incontinence (loss of urine) Prostate problem Urgency Urinary Tract infection Painful urination HEMOTOLOGIC Easy skin bruising Marked fatigue Prolonged bleeding Tender glands/lymph nodes MUSCULOSKELETAL Arthritis Osteoporosis Muscle tenderness Muscle spasms Muscle weakness Joint swelling in o Hands o Hips o Wrists o Knees MOOD Anxiety Depression Panic attacks Restlessness RESPIRATORY Chronic cough Bronchitis Emphysema Coughing of blood Night sweats Short of Breath Tuberculosis (TB) Asthma/Wheezing NEUROLOGICAL Fainting Headaches Numbness of arms or legs Problem with memory Confusion Stroke Seizures Head injury Tingling of hands/arms/legs SKIN Chronic skin itching Color changes of hands or feet in the cold Poor scarring/non-healing ulcer Skin rashes or hives Unusual moles LAST VISIT WITH Dentist Ophthalmologist Primary Care Doctor

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