Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program

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Transcription:

Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program If you are reading this you have been fortunate enough to qualify for a consultation with Dr. Zammito at no charge. This however does NOT mean that your case has been accepted. Your consultation today will determine if A) You are a legitimate candidate for this program and B) Your condition is serious enough to warrant your case being accepted for treatment. In the event your condition IS serious enough to warrant being considered for acceptance and Dr. Zammito is unable to treat you, your case will be referred to another clinic. Today's Date E-Mail address: Name Age Birthday Sex M F Address City State Zip Home Phone Work Phone Cell Phone Best Place To Reach You (circle one) Home / Work / Cell May we leave a voice mail message for you? Yes No Employer Occupation Length of Employ Marital Status S M W D Spouses Name SS# I (signature) consent to allow Dr. Zammito to speak with me and perform an examination (if necessary) in order to determine if I am a good candidate for non-surgical spinal decompression and also to determine if he is willing to accept my case. It is also my understanding that BOTH the consultation AND examination (if necessary) are at no charge. How Did You Hear About Jersey Shore Low Back Center? 1. How Serious Do You Think Your Problem Is? What Is Your Main Problem/Symptom Prompting Your Request For A Consultation With The Doctor? Would You Consider This Problem(circle one)... MINIMAL (Annoying but causing NO limitations) SLIGHT (Tolerable but causing a little limitation) MODERATE (Sometimes tolerable but definitely causing limitations) SEVERE (Causing Significant limitations) EXTREME (Causing near constant (>80% of the time) limitations) 1. In spite of the fact that you are not a back specialist, you are in fact the person who knows more about your back than anyone else. In your own words and in your own opinion what do you think the real problem is? 2. What are you hoping happens today as a result of your consultation with the Doctor? 3. Since your back pain became this severe what three things has it caused you to miss the most? 3. How long have you been like this?

4. How has your life changed since your back became a problem? 5. What activities are you limited in? 6. What kinds of treatments have you received? Epidural: How Many When(approx) Physical Therapy: How Long When(approx) Medication: When(approx) Surgery: Type When(approx) Other 7. When did you receive these treatments and for how long? 8. Did any of these treatments work? If so which one(s)? For how long? 9. Is there anything you can do that makes it feel better? 10. What activities/movements are guaranteed to make it worse? 11.Please describe the quality of the pain. (Sharp, Dull, achy, toothache, shooting, stabbing, numb, tingling, etc...) 12. Is it worse in the morning or is it worse as the day progresses? 13. If you cannot find a solution to this problem what do you think will happen to you? 14. What are you hoping Dr. Zammito tells you today?

15. Describe what you hope or think he might be able to do for you. 16.Describe what will be different in your life if you can get better. When is the VERY FIRST time you recall having this problem? List In Order Of Importance all OTHER Health Problems/Concerns NOT includng Your Main Problem Above. 1. How Long Have You Had This? 2. How Long Have You Had This? 3. How Long Have You Had This? 4. How Long Have You Had This? In Reference To Your MAIN PROBLEM How Often Are You Aware of This Problem? (circle one) Occasionally (25% of the time) Intermittently (50% of the time) Frequently (75% of the time) Constant (90-100% of the time) Due To Your Main Problem... Have You Lost Any Time From Work? Yes No Have You Lost Any Time From Your Chores/Tasks At Home? Yes No Have You Lost Any Time From Your Family? Yes No Have You Lost Any Time From Your Leisure Activities? (Hobbies, Travel, Sports, etc...) Considering the amount of pain/discomfort you've had THIS week, how long has your problem been this severe? On a Scale of 0-10 (10 being unbearable, 0 being No Pain or Discomfort) Please rate the following... The HIGHEST your pain gets WITHOUT medication The LOWEST your pain gets WITHOUT medication The HIGHEST your pain gets WITH medication The LOWEST your pain gets WITH medication List ANY surgeries that you have had and the corresponding dates.

Have you had ANY of the following in the last 12 months or currently. (Mark C for Current. X for in last 12 mos.) GENERAL Chills Convulsions Dizziness Fainting Fatigue Fever Headache Loss of Sleep Allergy (to what ) Loss of Weight Nervousness Wheezing Bronchitis Numbness in BOTH hands AND feet CARDIOVASCULAR High Blood Pressure Low Blood Pressure Pain over heart Poor Circulation Rapid Heartbeat Previous Heart Problem (Describe ) Slow Heartbeat Stroke TIA Swollen Ankles Varicose Veins Aortic Aneurysm Bruise Easily DISEASES/CONDITIONS Appendicitis Anemia Arthritis Alcoholism Abdominal Surgery Bleeding Disorder Blood Clot(s) Breathing Difficulty Cancer Cholesterol High Colon Problems Diabetes Depression Epilepsy Eczema Eating Disorder Glaucoma HIV + Heart Disease Hernia Headaches Influenza Kidney Disease Liver Disease Low back Pain Mental Illness Measles Mumps Pleurisy Pneumonia Polio Prostate Problems Hyperthyroid Hypothyroid Rectal Surgery EARS/EYES/NOSE/THROAT Asthma Crossed Eyes Double Vision Blurred Vision Difficulty Swallowing Deafness Hearing Loss Ear Pain Thyroid Problem Nose Bleeds Sinus Problems Sore Throats GASTRO-INTESTINAL Gas Colon Trouble Constipation Diarrhea Gallbladder Trouble Hemorrhoids Liver Trouble Nausea Stomach Ache Poor Appetite Poor Digestion Vomiting Vomiting Blood Rectal Bleeding Bloating GENITO-URINARY Blood in Urine Frequent Urination Inability to control urine Kidney Infection Painful Urination Prostate Trouble Painful Urination FOR MEN ONLY Lump in testicles Penis discharge FOR WOMEN ONLY Menstrual Cramps Excessive menstrual flow Hot Flashes Irregular Cycle Painful periods Birth Control Pills Abnormal Pap Smear MUSCLE/JOINT/BONE Backache Foot Trouble Pain Between Shoulders Painful Tailbone Stiff Neck Spinal Curvature Swollen Joints NEUROLOGIC Seizures Dizziness Hand Trembling Weakness Difficulty with speech Loss of memory Loss of coordination RESPIRATORY Chest Pain Chronic Cough Difficulty Breathing Coughing/Spitting Blood OFFICE USE ONLY: Pn. Loc.:

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