Spine New Patient Questionnaire Rev

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Spine New Patient Questionnaire Rev 10.13.10 Name: Male Female Temp: Height: Weight: Date of Visit: Date of Birth: Age Today: *Please note this is a multi-part questionnaire. When you are done, please take a moment to go over the questionnaire to be sure you have not missed any pages or questions. Than you for your help. 1. Pain Drawing: Mark these drawings using the symbol that best describes your pain quality. Numbness = = = = Ache ^ ^ ^ ^ Stabbing / / / / Burning x x x x Cramping + + + + Pins & Needles o o o o 3. If you have BACK pain... % back pain + % leg pain = 100% On a scale of 0 to 10, mark your level of current pain discomfort, with 0 being none and 10 being the worst pain you can imagine. Back Leg 4. If you have BACK pain... L R R L % neck pain + % arm pain = 100% On a scale of 0 to 10, mark your level of current pain discomfort, with 0 being none and 10 being the worst pain you can imagine. Neck 2. Which area is most painful? Low back Neck and/ Both are equal and/or legs or arms Arm Page 1 of 6

5. How did you first hear about TOC-Spine? Friend/Family Member Another Patient Internet Physician Other 6. What is the primary reason of your visit to TOC-Spine? Evaluation/Diagnosis/Treatment Second Opinion Education/Information Surgical planning 7. How did your current symptons begin? Suddenly Date: Gradually Please describe: 8. How long ago did your current symptoms begin? Less than 2 weeks ago 2 to 6 weeks ago 6 to 12 weeks ago 3 to 6 months ago 6 to 12 months ago More than 1 year 9. Is this a work-related injury? 10. Have you ever filed a Worker s Compensation claim for your back/neck symptoms in the past? 11. Did your pain begin after a car accident? (skip to question #12) If you were injured in a car accident please carefully fill out the questions below. Date of Action: Briefly describe the details of the accident: When did you first notice symptoms? When did you first report these to a doctor? Did you suffer any other injuries when you hurt your spine? If yes, please list: Have you ever been involved in a previous car accident? If yes, please describe: PAST MEDICAL HISTORY 12. Have you received treatment for your back or neck? If yes, what treatments have you had? Physical therapy Epidural/Caudal Injections Chiropractic Facet Injections Surgery Pain Management Anti-Inflammatories 13. Please mark any of the following medical problems you have had: Asthma Bleeding disorder Cancer (Type: ) Depression Diabetes (Insulin? Y or N) Emphysema/COPD Heart attack Heart disease Hepatitis (Type? ) High blood pressure HIV positive Kidney/bladder infections Kidney stones Prostate problems Psoriasis Rheumatoid arthritis Seizure disorder Sleep Apnea Stroke or TIA Thyroid problems Ulcers or reflux Ulcerative colitis Tuberculosis Other NONE Family HISTORY 14. please mark conditions in your immediate family: Anesthesia difficulties Arthritis Back Pain Bleeding tendencies Cancer (Type: ) Diabetes Heart Disease Stroke NONE Page 2 of 6

15. List all previous hospitalizations that were not for surgery: 15. Have you ever had previous BACK or NECK surgery? Yes NONE If yes, how many surgeries? Date of How long did the SPINE surgery Type of surgery % Improvement improvement last? Have you ever been involved in a previous car accident? After your most recent spine surgery, No Yes, with no limitations did you return to full function: ```` Did not work before surgery Yes, with limitations 16. List all previous surgeries UNRELATED to your spine: NONE Date of surgery Type of surgery Describe Recovery CURRENT MEDICATIONS AND ALLERGIES 17. Please list all medications and doses that you are CURRENTLY taking (include herbal supplements): NONE Medication Dose/Strength # Pills per Day Reason Example: diabetes, hypertension Medication Allergies: None Known Medication Reaction Medication Reaction Latex Allergy: Page 3 of 6

REVIEW OF SYSTEMS 18. Please list all medications and doses that you are CURRENTLY taking (include herbal supplements): NONE Skin rashes psoriasis bruise easily abnormal lumps painful breasts Eyes visual loss double vision Ears decreased hearing ringing in ears Nose sinus problems breathing problems Throat sore throat hoarseness snoring Cardiovascular palpitations heart murmur chest pain irregular heartbeat Respiratory shortness of breath wheezing cough Gastrointestinal weight loss nausea/vomiting constipation diarrhea blood in stool loss of bowel control Musculoskeletal fractures/sprains osteoporosis joint swelling Genitourinary blood in urine increased frequency of urination painful urination loss of bladder control kidney stones Endocrine thyroid problems excessive thirst/appetite diabetes Neurologic headache/migraine dizziness convulsions/seizures loss of consciousnes none OF THESE (OR NONE CURRENTLY) Social History WORK HISTORY 19. Do you currently smoke cigarettes? No, I have never smoked No, I quit months/ years ago Yes packs per day Currently Chew Tobacco/ Snuff 20. Do you use alcoholic beverages (beer, wine, liquor)? If yes, type of alcohol Amount 21. Current situation Married Divorced Single Living with significant other Widowed 22. Do you have children? If yes, list their ages: How many children are living with you? 23. What is your occupation? Name of employer: Last date worked: 24. Please mark ONE statement that best describes your current employment situation: Currently working On paid leave On unpaid leave Unemployed Homemaker Student Retired (not due to health) Disabled and/or retired because of my back or neck problems Disabled due to a health problem not related to my back or neck Other, please specify Page 4 of 6

25. Modified Oswestry Disability Index: This questionnaire has been designed to give your doctor information as to how your pain as affected your ability to manage in everyday life. Please answer every question marking the ONE box that best describes your condition today. We realize you may feel that two of the statements may describe your condition, but please mark only the box that most closely describes your current condition. Pain Intensity I can tolerate the pain I have without having to use pain medication. The pain is bad, but I can manage without having to take pain medication. Pain medication provides me with complete relief from pain. Pain medication provides me with moderate relief from pain. Pain medication provides me with little relief from pain. Pain medication has no effect on my pain. Personal Care (e.g., Washing, Dressing) I can take care of myself normally without causing increased pain. I can take care of myself normally, but it increases my pain. It is painful to take care of myself, and I am slow and careful. I need help, but I am able to manage most of my personal care. I need help every day in most aspects of my care. I do not get dressed, I wash with difficulty, and I stay in bed. Lifting I can lift heavy weights without increased pain. I can lift heavy weights, but it causes increased pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (e.g., on a table). Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can lift only very light weights. I cannot lift or carry anything at all. Walking Pain does not prevent me from walking any distance. Pain prevents me from walking more than 1 mile. (1 mile = 1.6 km). Pain prevents me from walking more than 1/2 mile. Pain prevents me from walking more than 1/4 mile. I can walk only with crutches or a cane. I am in bed most of the time and have to crawl to the toilet. Sitting I can sit in any chair as long as I like. I can only sit in my favorite chair as long as I like. Pain prevents me from sitting for more than 1 hour. Pain prevents me from sitting for more than 1/2 hour. Pain prevents me from sitting for more than 10 minutes. Pain prevents me from sitting at all. Sleeping Pain does not prevent me from sleeping well. I can sleep well only by using pain medication. Even when I take medication, I sleep less than 6 hours. Even when I take medication, I sleep less than 4 hours. Even when I take medication, I sleep less than 2 hours. Pain prevents me from sleeping at all. Social Life My social life is normal and does not increase my pain. My social life is normal, but it increases my level of pain. Pain prevents me from participating in more energetic activities (e.g., sports, dancing). Pain prevents me form going out very often. Pain has restricted my social life to my home. I have hardly any social life because of my pain. Traveling I can travel anywhere without increased pain. I can travel anywhere, but it increases my pain. My pain restricts my travel over 2 hours. My pain restricts my travel over 1 hour. My pain restricts my travel to short necessary journeys under 1/2 hour. My pain prevents all travel except for visits to the physician/ therapist or hospital. Employment / Homemaking My normal homemaking / job activities do not cause pain. My normal homemaking / job activities increase my pain, but I can still perform all that is required of me. I can perform most of my homemaking / job duties, but pain prevents me from performing more physically stressful activities (e.g., lifting, vacuuming). Pain prevents me from doing anything but light duties. Pain prevents me from doing even light duties. Pain prevents me from performing any job or homemaking chores Standing I can stand as long as I want without increased pain. I can stand as long as I want, but it increases my pain. Pain prevents me from standing for more than 1 hour. Pain prevents me from standing for more than 1/2 hour. Pain prevents me from standing for more than 10 minutes. Pain prevents me from standing at all. Page 5 of 6

I authorize Dr. Bolt and Tennessee Orthopaedic Clinics to release my medical reports to my referring physician and/or attorney if applicable. REFERRING CARE PHYSICIANS: Phone: Address: REFERRING CARE PHYSICIANS FAX Number: REFERRING CARE PHYSICIANS EMAIL ADDRESS: ATTORNEY S Name: Phone: Address: ATTORNEY s FAX Number: Patient s Signature: please Print Name: Patient Email Address (optional) Page 6 of 6

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