FLORIA ORTHOPAEIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE Please circle answers t questins that pertain t yur prblem. Yu may select mre than ne answer per questin. This infrmatin will help get an accurate appraisal f yur prblems, develp an apprpriate plan f treatment, and will be included in yur visit nte. If yu have any questins, please ask fr assistance. Referred by: Is this a secnd pinin? NAME. MR# ATE. R AGE: ARE YOU: (A) Right handed (B) Left handed (C) Ambidextrus SEX: (A) Male (B) Female OCCUPATION: COMPLAINT (What are yu being seen fr?) A. Neck pain B. Neck Pain with headaches C. Upper Back Pain. Lwer Back Pain E. Right Leg Pain F. Left Leg Pain G. Right Arm Pain H. Left Arm Pain I. Sclisis J. Other yu have any: A. Weakness B. Numbness C. Tingling. If s, where? escribe ---------- If ne r mre f the abve is chsen, which is the mst prblematic? Which term best describes yur neck/back pain? A. A. Sharp B. Stabbing C. Burning. Like electricity E. ull ache F. Pins and needles When did the prblem start? Which term best describes yur arm/leg pain? A. Sharp B. Stabbing C, Burning. Like electricity E. ull ache F. Pins and needles If prblem was caused frm an injury, what is the date f injury? Was the injury jb related? (A) Yes (B) N Hw did the injury ccur? A. N injury B. Mtr vehicle accident - n litigatin C. Mtr vehicle accident - litigatin pending. Mtr vehicle accident - litigatin cmplete E. Fall F. Sprts r recreatin G. Jb related H. Other If mtr vehicle accident, were yu: A. river B. Frnt seat passenger C. Rear seat passenger. Mtrcycle driver E. Mtrcycle passenger F. Other --------- Were yu wearing a seat belt? (A) Yes (B) N Other injuries due t this cnditin: (A) Nne (8) Yes, explain
*If yu are being seen fr BACK PAIN, please cmplete the fllwing questins: (Lw Back) Pain Intensity b I have n pain at the mment. 0 The pain Is very mild at the mment. 0 The pain Is mderate at the mment. O The pain Is fairly severe at the mment. O The pain is very severe at the mment. 0 The pain Is the wrst imaginable at the mment. (Lw Back) Persnal Care (washing, dressing, etc.) O I can lk after myself nrmally withut causing extra pain. 0 I can lk after myself nrmally, but it causes extra pain. 0 It Is painful t lk after myself and I am slw and careful. 0 I need sme help, but manage mst f my persnal care. 0 I need help every day In mst aspects f self-care. 0 I d nt get dressed; I wash with difficulty and stay in bed. (Lw Back) Lifting 0 I can lift heavy weights withut extra pain. O I can lift heavy weights, but it gives extra pain. 0 Pain prevents me frm lifting heavy weights ff the flr, but I can manage if they are cnveniently psitined, fr example, n a table. 0 Pain prevents me frm lifting heavy weights, but I can manage light t medium weights if they are cnveniently psitined. O I can lift very light weights. O I cannt 11ft r carry anything at all. Walking 0 Pain des nt prevent me walking any distance O Pain prevents me frm walking mre than 1 mile 0 Pain prevents me frm walking mre than ½ mile O Pain prevents me frm walking mre than 100 yards O I can nly walk using a stick r crutches 0 I am In bed mst f the time Sitting O I can sit in any chair as lng as I like 0 I can nly sit in my favrite chair as lng as I like O Pain prevents me sitting mre than ne hur O Pain prevents me frm sitting mre than 30 minutes O Pain prevents me frm sitting mre than 1 O minutes 0 Pain prevents me frm sitting at all Standing 0 I can stand as lng as I want withut extra pain O I can stand as lng as I want but it gives me extra pain O Pain prevents me frm standing fr mre than 1 hur O Pain prevents me frm standing fr mre than 30 minutes 0 Pain prevents me frm standing fr mre than 10 minutes O Pain prevents me frm standing at all (Lw Back) Sleeping 0 I have n truble sleeping. 0 My sleep Is slightly disturbed (less than 1 hur sleepless). 0 My sleep is mildly disturbed (1-2 hurs sleepless). 0 My sleep Is mderately disturbed (2-3 hurs sleepless). 0 My sleep is greatly disturbed (3-5 hurs sleepless). 0 My sleep is cmpletely disturbed (5-7 hurs) Sex Life (if applicable) 0 My sex life is nrmal and causes n extra pain 0 My sex life is nrmal but causes sme extra pain 0 My sex life is nearly nrmal but Is very painful 0 My sex life is severely restricted by pain 0 My sex life Is nearly absent because f pain 0 Pain prevents any sex life at all Scial Life O My scial life is nrmal and gives me n extra pain 0 My scial life is nrmal but Increases the degree f pain 0 Pain has n significant effect n my scial life apart frm limiting my mre energetic Interests e.g. sprt O Pain has restricted my scial life and I d nt g ut as ften O Pain has restricted my scial life t my hme O I have n scial life because f pain Traveling 0 I can travel anywhere withut pain O I can travel anywhere but it gives me extra pain 0 Pain is bad but I manage jurneys ver tw hurs 0 Pain restricts me t jurneys f less than ne hur O Pain restricts me t shrt necessary jurneys under 30 minutes 0 Pain prevents me frm travelling except t receive treatment 4
CERVICAL VISUAL ANALOGUE SCALE Name MR# ate INSTRUCTIONS: Please mark a vertical line that best describes yur pain at the mment. EXAMPLE: N pain -------------;--- As severe as it culd be Neck: N pain ARM: As severe as it culd be scre N pain -----------~---------As severe as it culd be scre Mark the area(s) n yur bdy where yu feel the described sensatin(s). Use the apprpriate symbl(s). Mark areas f radiating pain, and include all affected areas. Yu may draw n the face as well. Aches AAA/\ Numbness 0000 Pins/Needles Burning xxxx Stabbing////
NECK ISABILITY INEX Name MR# ate This questinnaire has been designed t give the dctr infrmatin as t hw yur neck pain has affected yur ability t manage in everyday life. Please answer every sectin and mark in each sectin nly ONE bx which applies t yu. We realize yu may cnsider that tw f the statements in any ne sectin relate t yu, but please just mark the bx which MOST CLOSELY describes yur prblem. Sectin 1 - Pain Intensity I have n pain at the mment. The pain ls very mild at the mment. The pain Is mderate at the mment. The pain Is fairly severe at the mment. The pain ts very severe at the mment. The pain Is the wrst imaginable at the mment. Sectin 2 -- Persnal Care (Washing, ressing, etc.} I can lk after myself nrmally withut causing extra pain. I can lk after myself nrmally but ft causes extra pain. It is painful t tk after myself and I am slw and careful. I need sme help but manage mst f my persnal care. I need help every day ln mst aspects f self care. I d nt get dressed, I wash with difficulty and stay in bed. Sectin 3 - Lifting I can lift heavy weights withut extra pain, I can lift heavy weights but it gives extra pain. Pain prevents me frm Ufting heavy weights n tne flr, but I can manage If they are cnveniently psltfned, fr example n a table. Pain prevents me frm lifting heavy weights, but I can manage llght t medium weights if they are cnveniently psmne. I can lift very light weights. I cannt lift r carry anything at an. Sectin 4 - Reading I can read as much as I want t with n pain ln my neck. I can read as much as I want t with slight pain in my neck. I can read as much as I want with mderate pain. I can't read as much as I want because f mderate pain in my neck. I can hardly read at all because f severe pain in my neck. I cannt read at all. Sectin 5-Headaches I have n headaches at all. I have slight headaches whlch cme Infrequently. I have slight headaches which cme frequently. I have mderate headaches which cme infrequently. I have severe neaacnes which cme frequently. I have headaches almst an the time. Scring: Questins are scred n a vertical scale f 0-5. Ttal scres and multiply by 2. ivide by number f sectins answered multiplied by 'IO. A scre f 22% r mre is cnsidered a significant activities f daily living disability. (Scre x 2) / (Sectins x 10) = %AOL Sectin 6 - Cncentratin I can cncentrate fully when I want t with n difflculty. I can cncentrate fully when l want t with slight dlfficutty. I have a fair degree f difficulty In cncentrating When I want t. I nave a lt f difficulty in cncentrating when I want t. I have a great deal f difficulty in cncentrating when I want t. I cannt cncentrate at an. Sectin 7-Wrk I can d as much wrk as I. want t. I can nly d my usual wrk, but n mre. I can d mst f my usual wrk, but n mre.. I cannt d my usual wrk. I can hardly d any wrk at all. l can't d any wrk at all. Sectin 8- riving I nve my car withut any neck paln. I can drlve my car as lng as I want with slight pain ln my neck. l can nve my car as lng as I want with mderate pain In my neck. I can't drive my car as lng as I want because f mderate pain in my neck. I can hardly drive my car at an because f severe pain In my neck. I can't drive my car at all. Sectin 9 - Sleeping I have n truble sleeping. My steep is slightly disturbed (less than 1 hr. sleepless). My sleep is mderately disturbed (1-2 hrs. sleepless). My sleep is mderately disturbed (2-3 hrs. sleepless}. My sleep is greatly disturbed (3-4 hrs. sleepless). My sleep is cmpletely disturbed (5-7 hrs. sleepless}. Sectin 10 - Recreatin I am able t engage in all my recreatin activities with n neck pain at all I am able t engage in an my recreatin actmties, with sme pain in my neck. I am able t engage in mst, but nt all f my usual recreatin actlvlnes because f pain in my neck. I am able t engage in a few f my usual recreatin activities because f pain In my neck. I can hardly d any recreatin activities because f pain in my neck. I can't d any recreatin actlvlties at all. Cmments...,. Reference: Vernn, Mir. JMPT 1991; '14(7): 409-'15
EQ-5-SL Health Questinnaire Name MR# ate Under each heading, please tick the ONE bx that best describes yur health TOAY. MOBILITY I have n prblems in walking abut I have slight prblems in walking abut I have mderate prblems in walking abut I have severe prblems in walking abut I am unable t walk abut SELF-CARE I have n prblems washing r dressing myself I have slight prblems washing r dressing myself I have mderate prblems washing r dressing myself I have severe prblems washing r dressing myself I am unable t wash r dress myself USUAL ACTIVITIES (e.g. Wrk, study, husewrk, family r leisure activities) I have n prblems ding my usual activities I have slight prblems ding my usual activities I have mderate prblems ding my usual activities I have severe prblems ding my usual activities I am unable t d my usual activities PAIN/ ISCOMFORT I have n pain r discmfrt I have slight pain r discmfrt I have mderate pain r discmfrt I have severe pain r discmfrt I have extreme pain r discmfrt ANXIETY/ EPRESSION I am nt anxius r depressed I am slightly anxius r depressed I am mderately anxius r depressed I am severely anxius r depressed I am extremely anxius r depressed [~ We wuld like t knw hw gd r bad yur health is TOAY. This scale is numbered frm 0-100. 100 means the best health yu can imagine. 0 means the wrst health yu can imagine. Mark an X n the scale t indicate yw yur health is TOAY. Please put that scre in this bx.
6 PAST MEICAL/SURGICAL HISTORY yu have a histry f any f these medical cnditins? iabetes YES NO High chlesterl YES NO -- iet cntrlled Liver disease YES NO -- Medicatin cntrlled Kidney disease YES NO Insulin cntrlled Hepatitis YES NO High bld pressure YES NO Type? Heart disease YES NO Immune disrder YES NO Chest pain/angina Seizures YES NO Heart attack, ate Eye prblems YES NO Valve disease Headaches YES NO Cancer/Tumr YES NO Thyrid disrder YES NO What type? Ostearthritis (wear and tear) YES NO Ulcers YES NO Rheumatid arthritis YES NO Lung disease including emphysema YES NO Asthma YES NO Strke YES NO Mental disrder YES NO When? Explain Circulatin prblems YES NO Other Have yu ever had any neck r back (spine) surgery? A. N B. Yes: Hw many? Please list yur previus neck and back (spine) peratins. Surgen Prcedure Have yu had any ther surgery besides spine? A. N B. Yes: Please list belw Prcedure
7 A. Nne B. Yes: Please list belw CURRENT MEICATIONS Fr what prblem? ALLERGIES yu have any Allergies? A. N knwn allergies including idine/cntrast dye r shellfish B. Yes, please list SOCIAL AN FAMILY HISTORY Marital status: (A) Single (B) Married (C) ivrced () Widwed Hw many children d yu have? What is the highest level f educatin yu have cmpleted? {A) Sme high schl (B) High schl (C) Trade schl () Cllege (E) Prfessinal schl yu smke? (A) N (B) Yes; packs per day? Hw many years have yu been smking? yu smke a pipe? yu smke cigars? yu use smkeless tbacc? (A) N (A) N (A) N (B) Yes Hw ften? (B) Yes Hw ften? (B) Yes Hw much? id yu ever smke regularly befre? {A) N (B) Yes; packs per day? Hw many years did yu smke? When did yu quit smking? Hw much alchl d yu cnsume in an average week (beer, wine, etc.)? A. Nne B. Less than 6 drinks C. 6-12 drinks. 12-24 drinks E. 24-48 drinks F. Mre than 48 drinks
8 What is yur current wrk status? A. Regular emplyment - n restrictins B. Full time with restrictins C. Part time by chice. Part time with restrictins E. Part time due t a spine prblem F. Part time due t ther medical reasn, Specify --'- G. Retired by chice H. Retired due t a spine prblem I. Retired due t ther medical reasn, Specify J. Unemplyed - lking fr wrk with n restrictins K. Unemplyed - lking fr light duty wrk L. Unemplyed M. Currently nt wrking due t a spine prblem N. Currently nt wrking due t ther medical reasn, Specify ----------- 0. Student yu have a family histry f any f these diseases? (Circle all that are apprpriate) A. Nne G. Ostearthritis (wear & tear) B. Back r neck prblems H. Rheumatid arthritis C. Cancer I. Sclisis. iabetes J. Strke E. Heart disease K. Other F. Hypertensin REVIEW OF SYSTEMS Have yu recently experienced any f the fllwing? General: Heart: Weight gain YES NO Chest pain YES NO Weight lss YES NO Palpitatins YES NO Fever YES NO Fainting YES NO Chills YES NO GU: Night sweats YES NO Frequent urinatin YES NO Skin: ifficulty with urinatin YES NO Change in mles YES NO Bld in urine YES NO Breast lumps YES NO Vascular: Eyes: Swelling lwer extremities YES NO Lss f visin YES NO Embli (bld clts) YES NO uble visin YES NO Musculskeletal: ENT: Muscle weakness YES NO Hearing lss YES NO Stiffness YES NO Nse bleeds YES NO Jint pain YES NO GI: Psych: Nausea YES NO Anxiety YES NO Vmiting YES NO epressin YES NO Change In bwel habits YES NO Cnfusin YES NO Heartburn YES NO Memry lss YES NO Respiratry: Shrtness f breath YES NO Cughing/wheezing YES NO r. signature
Patient Name ate MR#: ---------- ------- ---- Pharmacy Name PREFRERRE PHARMACY INFORMATION Pharmacy Street Address City, State, Zip If address unknwn please prvide crssrads Pharmacy Phne Number Everything I have answered Is true and crrect t the best f my knwledge, Patient Signature: ate: 12/26/2012