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Dr. Byers Dr. Su Dr. Sponzilli Lisa Elvin, NP Spine Center New Patient Form Last Name First Name Middle Name MRN This form is used to gather information so that my doctor can maximize the time used to examine me and answer my questions about my condition and treatment options. I certify that the following information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may make in the completion of this form. Patient Signature (Date) Physician Signature (Date) Definitions Carefully read the following definitions Pain Levels Neck Pain Arm Pain Back Pain Leg Pain The level of pain you have had on average since your problem began Neck includes middle of neck, upper shoulders, between shoulder blades Arm includes shoulder, arm, or hand Back includes pain above the belt line across the lower back Leg includes areas below the belt line including the buttock, legs, or feet Age Hand Dominance Gender What is the main complaint you wish to discuss? Right Left Male Female What was the approximate date your problem started? Which best describes the onset of the problem Gradual Onset Sudden Onset If sudden onset, what were you doing when it started? i.e. fell off ladder, golfing, lifting groceries Did your problem begin with a car accident? No Yes If yes: Were you the driver? Were you wearing a seatbelt? Did you pass out? When did you first seek medical attention? Less than 1 month 1-3 months 3-6 months 6 months to 1 year 1-2 years More than 2 years March 2018 Spine New Patient Form BWS Page 1

FRONT BACK For a total of 100%, what % is back pain and what % is leg? % Low Back Pain % Leg Pain (i.e. 30% low back pain with 70% leg pain) + =100% For a total of 100%, what % is neck pain and what % is arm? % Neck Pain % Arm Pain (i.e. 20% neck pain with 80% arm pain) + =100% Your level of pain from 0 to 10 0 1 2 3 4 5 6 7 8 9 10 Less Pain Worse Pain Neck Pain Right Arm Pain Left Arm Pain Low Back Pain Right Leg Pain Left Leg Pain Using the symbols, mark the location and type of pain on the diagrams RIGHT LEFT LEFT RIGHT If you have pain into the lower leg, feet, or hands, make sure you note it Type of Sensation: Stabbing/Burning: ^ Aching: X Pins and Needles: Numbness: O Do you have: No Yes Explain where Numbness in the arms/hands or legs/feet? Weakness in the arms/hands or legs/feet? March 2018 Spine New Patient Form BWS Page 2

Pain worse with Rest Lying flat Sitting Standing Walking on flat surfaces Walking up/down stairs Bending /twisting Other (Describe) Pain better with Do you have: No Yes Loss of bowel control? (difficulty controlling/initiating bowel movements or incontinence) Loss of bladder control? (difficulty controlling/initiating urination or incontinence) Night pain for which you change position or get out of bed? Balance problems from leg weakness? Balance problems not from weakness but from lack of coordination? Problems handling small objects such as coins or problems buttoning your shirts? Treatment history No Yes Details (If Yes) Anti-inflammatory pain medicine (ie Motrin, Aleve) Narcotics (ie Vicodin, Percocet) Epidurals or Selective Root injections Physical Therapy Physiatrist (Pain Specialist) Acupuncture Chiropractor Medication: Medication: How many: Date of last injection: How long: Made my pain: Better No Change Worse Medical history (ie: High blood pressure, asthma, high cholesterol, etc) I have no medical problems Do you have history of cancer? No Yes Details (If Yes) Type: Prior treatment: March 2018 Spine New Patient Form BWS Page 3

Surgical history (i.e.:tonsillectomy, hip replacement, heart surgery, etc) I have not had surgery in the past Date of Surgery Surgery (Specify Right or Left side if relevant) List ALL medications, vitamins, and supplements you are currently taking. (May attach list of medications) I currently take no medications Allergic reactions including medicines, iodine, intravenous dye, latex, shellfish, etc. Medication/Substance Allergic Reaction I have no allergies Occupational/Social history What is your occupation? I am currently retired No Yes Details (If Yes) Are you out of work due to your spinal condition? Do you have a workman s compensation claim? How long have you been out of work? Date of work injury: Do you smoke cigarettes? Do you smoke a pipe or cigars? Do you dip snuff or chew tobacco? Do drink alcohol? Do you use any street drugs? How many packs per day? For how many years? How often? How often? How many drinks per week? Which drugs and how often? Who do you live with? March 2018 Spine New Patient Form BWS Page 4

Family history of disease I have no family history of disease Relationship Disease Relationship Disease Review of systems General Eye,Ear Nose,Throat Musculoskeletal Psychiatric Fever or Chills Difficulty swallowing Joint pains Anxiety Dizziness Hearing loss Muscle aches Depression Fainting spells Hoarseness Ankylosing spondylitis Psychiatric hospitalization Fatigue Nose bleeds Weak bones Panic attacks Frequent headaches Ringing in ears Rheumatoid arthritis Suicidal thoughts Insomnia Sinus problems Osteoarthritis Psychiatric drugs Sweats Blurry vision Bone cancer Memory loss Weight changes Poor vision Bone infections Other: Other: Other: Other: MEN only Cardiovascular Gastrointestinal Genitourinary Breast lumps Ankle swelling Poor appetite Bladder control Enlarged prostate Chest pains Bowel changes Blood in urine Erectile dysfunction Enlarged heart Constipation Frequent urination Penis discharge Heart attack Diarrhea Kidney stones Prostate cancer Heart murmur Excessive thirst Painful urination Other: Heart palpitations Heartburn Urgent urination WOMEN only High blood pressure Nausea Weak stream Abnormal pap smear Shortness of breath Rectal bleeding Other: Breast lumps Irregular heartbeat Stomach pain Neurological Vaginal discharge Prolonged bleeding Ulcers Loss of motor control Severe menstrual pain History of blood clots Vomiting Weakness Hot flashes Other: Other: Paralysis Other: Endocrine Skin Poor balance Date of last period: Blood sugar problem Bruise easily Seizures Age periods began: Use of steroids Foot ulcers Speech difficulties Age of menopause: Over active thyroid Rashes Tremors Are you pregnant? Under active thyroid Sores that won t heal Muscle wasting # of pregnancies? Other: Other: Other: # of live births? Office Use Only Height Weight BP / Pulse March 2018 Spine New Patient Form BWS Page 5

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