Past Surgical History

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Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression o Diabetes o Emphysema/COPD o Epilepsy o Fibromyalgia o Gout o Heart Attack o Heart Failure o Hepatitis o HIV/AIDS o Hypertension o Irregular Heart Beat o Kidney Failure o Lung Disease o Mental Illness o MRSA o Osteoarthritis o Seizures o Stomach Ulcers o Stroke o Tuberculosis Past Surgical History Have you ever had surgery? No Yes Please list any surgeries and/or hospitalizations and year:

Medication History Please list your current medications and bring list to your appointment (Over the counter, Prescriptions, Herbal, etc) Name of Medication Dose/ Strength Frequency Allergies Are you allergic to anything? No Yes Please list any allergies:

Family History Check All That Apply Aneurysm Back/Neck Problems Bleeding Disorder Brain Tumor Cancer Depression Epilepsy Heart Disease Muscle Disease Parkinson s Disease Stroke Other Social History Marital Status: Married Single Widowed Divorced Highest level of education: I live: Alone With: Tobacco Use: Never Cigar Chew Pipe Cigarettes ( packs/day for years). Quit- When Alcohol: Never Rarely Social Frequently Recovering Alcoholic Drug Use: Never Currently In the past Which ones? Current Work Status: Full time Part time Unemployed Retired Disabled If disabled, since what time? Occupation (if retired list prior occupation) Does work require long Standing Sitting Walking Lifting Does it include heavy labor? How much are you required to lift?

Check all that apply Constitutional o Fatigue o Fever o Loss of Appetite o Weight gain in last 12 mos o Weight loss in last 12 mos Eyes o Blurred Vision o Double Vision o Light Sensitivity o Loss of Vision HENT o Bleeding Gums o Loss of Hearing o Loss of Taste/Smell o Nose Bleeds o Ringing (Tinnitus) Cardiovascular o Chest Pains o High Blood Pressure o Low Blood Pressure o Heart racing Review Of Systems Respiratory o Shortness of Breath o Wheezing Gastrointestinal o Nausea o Vomiting o Diarrhea o Bowel Accidents Genitourinary o Incontinence o Urinary Hesitance o Urinary Frequency o Sexual Difficulty Integument o Skin Sores o Abscess Musculoskeletal o Fractures o Gait Problems/Coordination Neurologic o Headaches o Seizures/Epilepsy o Loss of Consciousness o Dizziness / Vertigo o Paralysis/ Weakness o Numbness o Speech Difficulties o Confusion o Falls o Tingling o Head Injury Endocrine o Excess Thirst o Glandular or Hormone Problems Psychiatric o Memory Loss or Confusion o Anxiety Heme-Lymph o Bleeding Tendencies o Blood Clots

Where are your symptoms primarily located? Neck Lower back Other When did these symptoms start? How long? Do you have pain radiating into the extremities? Constant Intermittent Right arm Left arm Right Leg Left Leg Buttock Only Please mark those that apply: Numbness Sharp pain Burning Dull Throb Constant Intermittent What makes your pain worse? Sitting Standing Lying down Walking What makes your pain better? Sitting Standing Lying down Lifting Walking Medications Rest Ice Heat Have you ever lost control of your bowel or bladder? Yes No If yes, please describe: Is the pain a result of: Auto accident Fall Is there a lawsuit pending involving the injury? Yes No Physical Therapy: Yes No How many sessions? When What Facility? Symptoms/Previous Treatment Epidural or other types of injections? Yes No How many When What Facility? Is this a worker s comp injury? Yes No EMG testing: No Yes Where performed Prior Surgery on Cervical or Lumbar Spine? No Yes What procedure? Date of procedure? Who performed? Patient Signature Please mark the location of your pain on the diagram.

Pain Scale This questionnaire is designed to enable us to understand how much your pain has affected your ability to manage everyday activities. Please circle the 1 choice which closely describes your problem right now. Section 1- Pain Intensity A. The pain comes and goes and is very mild. B. The pain is mild and does not vary much. C. The pain comes and goes and is moderate. D. The pain is moderate and does not vary much. E. The pain is severe but comes and goes. F. The pain is severe and does not vary much. Section 2- Personal Care A. I would not have to change my way of washing or dressing in order to avoid pain. B. I do not normally change my way of washing or dressing even though it causes some pain. C. Washing and dressing increase the pain, but I manage not to change my way of doing it. D. Washing and dressing increase the pain and I find it necessary to change my way of doing it. E. Because of the pain, I am unable to do some washing and dressing without help. F. Because of the pain, I am unable to do any washing and dressing without help. Section 3- Lifting A. I can lift heavy weights without extra pain. B. I can lift heavy weights but it causes extra pain. C. Pain prevents me from lifting heavy off the floor, but I can manage if they are easily located, e.g. on a table. D. Pain prevents me from lifting heavy weights, but I can lift light to medium weights if they are easily located. E. I can only lift very light weights at the most. F. I cannot lift or carry anything at all. Section 4- Walking A. I have no pain walking. B. I have some pain with walking but does not change. C. I cannot walk more than 1 mile without increasing pain. D. I cannot walk more than ½ mile without increasing pain. E. I cannot walk more than ¼ mile without increasing pain. F. I cannot walk without increasing pain. Section 5- Sitting A. I can sit in any chair as long as I like without pain. B. I can only sit in my favorite chair as long as I like. C. Pain prevents me from sitting more than an hour. D. Pain prevents me from sitting more than ½ hour. E. Pain prevents me from sitting more than 10 minutes. F. Pain prevents me from sitting at all. Section 6- Standing A. I can stand as long as I want without pain. B. I have some pain with standing that does not increase with time. C. Pain prevents me from standing for greater than 1 hour. D. Pain prevents me from standing for greater than ½ hour. E. Pain prevents me from standing more than 10 minutes. F. I avoid standing because it increases pain right away. Section 7- Sleeping A. I get no pain in bed. B. I get pain in bed, but it does not prevent me from sleeping. C. Because of pain, my normal night s sleep is reduced by less than one-quarter. D. Because of pain, my normal night s sleep is reduced by less than one-half. E. Because of pain, my normal night s sleep is reduced by less than three-quarters. F. Pain prevents me from sleeping at all. Section 8- Social life A. My social life is normal and gives me no pain. B. My social life is normal but increases the degree of my pain. C. Pain has no significant effect on my social life apart from my more energetic interests e.g. dancing D. Pain has restricted my social life, and I do not go out often. E. Pain has restricted my social life to my home. F. I have no social life because of pain. Section 9- Traveling A. I have no pain with traveling. B. I get some pain with traveling, but none of usual forms of traveling make it worse. C. I get extra pain with traveling, but it does not compel me to seek alternative forms of travel. D. I get extra pain with traveling, which compels me to seek alternative forms of travel. E. Pain restricts me to short necessary journeys under ½ hour. F. Pain restricts all forms of travel. Section 10- Changing degree of pain A. My pain rapidly getting better. B. My pain fluctuates, but overall is definitely getting better. C. My pain seems to be getting better, but improvement is slow at present. D. My pain is neither getting better nor worse. E. My pain is gradually worsening. F. My pain is worsening every day.

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