FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE

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FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE Please circle answers to the questions that pertain to your problem. You may select more than one answer per question. This information will help get an accurate assessment of your problems, develop an appropriate plan of treatment, and will be included in your visit note. If you have any questions, please ask for assistance. Referred by: Is this a second opinion? NAME: MRN# DATE AGE: GENDER: MALE FEMALE OCCUPATION: SIGNATURE: What are you being seen for? How long has your pain been going A.) Neck pain on? B.) Arm pain C.) Back pain Is it worsening or improving? D.) Leg pain E.) Scoliosis F.) Other: Rate your neck/back pain on average from 0 to 10 (10 being the worst pain you ve ever felt). Rate your arm/leg pain on average from 0 to 10 (10 being the worst pain you ve ever felt). Please place 1 vertical mark on the line below indicating the breakdown of your pain. The closer the mark is to a side the more pain you have in that particular area. NECK/BACK ARM/LEG Which term best describes your arm/leg pain? A.) Sharp B.) Stabbing C.) Burning D.) Dull ache E.) Pins/needles Which term best describes your neck/back pain? A.) Sharp B.) Stabbing C.) Burning D.) Dull ache E.) Pins/needles If this problem was caused from an injury, what was the approximate date of the injury? Was the injury job related?

2 FLORIDA ORTHOPAEDIC INSITUTE SPINE CENTER PAIN ASSESSMENT F O R M Draw the location of your pain on the Figures b elow. For symptoms of pain, fill in the affected areas with the following pattern: xxxxx For symptoms of numbness and/or tingling, fill in the affected areas with the following pattern: ooooo 0% (No Pain) 100% (Worst Possible Pain) PAIN LINE: Draw a perpendicular line across the line above to indicate your typical level of daily pain. Other injuries due to this condition: (A) None (B)Yes, explain

Please briefly explain the circumstances that led to your condition: 3 What treatments have you already received for this condition? A. Medications (list) B. Physical therapy (how many weeks?) C. Chiropractic care (how many weeks?) D. Epidural injections: How many injections? When was the last? E. Other (please list) Since the pain/condition began it: What time of the day is pain most intense? A. Has improved A. On first arising in the morning B. Has worsened B. During the daytime or while at work C. Has stayed the same C. At the end of the day before bedtime D. Comes and goes (fluctuates) D. During the night What aggravates the pain? What makes the pain better? A. Walking A. Sitting B. Standing B. Lying down C. Sitting C. Walking D. Lying down D. Standing E. Activity in general E. Nothing in particular F. Stooping/bending F. Other/comments G. Nothing in particular H. Other/comments Does the pain awaken you from sleep? Does the pain keep you from sleeping? A. Never A. Never B. Occasionally B. Occasionally C. Frequently C. Frequently

4 Do you have any difficulty walking? Is walking difficulty related to this condition? A. Yes B. Yes, can walk unlimited distances B. No, explain C. Yes, can walk less than a mile D. Yes, can walk only 1-2 blocks E. Yes, can walk less than 1 block F. Yes, non-ambulatory (cannot walk) G. Other Have you had any problems with bowel, bladder, or sexual functions since this condition began? B. Yes: Please explain Have you had a previous back or neck problem? B. Yes: Explain Do you exercise regularly? B. Yes: How often? PAST MEDICAL/SURGICAL HISTORY Do you have a history of any of these medical conditions? Diabetes Diet controlled Medication controlled Insulin controlled High blood pressure Heart disease Chest pain/angina Heart attack, Date Valve disease Liver disease Kidney disease Hepatitis Type? Immune disorder Seizures Eye problems Cancer/Tumor Headaches What type? Ulcers Thyroid disorder Osteoarthritis (wear and tear) Lung disease including emphysema Rheumatoid arthritis Stroke Asthma When? Circulation problems High cholesterol

Mental disorder Explain Other 5

6 Have you ever had any neck or back (spine) surgery? B. Yes: How many? Please list your previous neck and back (spine) operations. Date Place Surgeon Procedure Have you had any other surgery besides spine? B. Yes: Please list below Date Procedure ne B. Yes: Please list below CURRENT MEDICATIONS Name Dose For what problem?

7 ALLERGIES Do you have any Allergies? known allergies including iodine/contrast dye or shellfish B. Yes, please list SOCIAL AND FAMILY HISTORY Marital status: (A) Single (B) Married (C) Divorced (D) Widowed How many children do you have? What is the highest level of education you have completed? (A) Some high school (B) High school ( C) Trade school (D) College (E) Professional school Do you smoke? (A) No (B) Yes; packs per day? How many years have you been smoking? Do you smoke a pipe? (A) No (B) Yes How often? Do you smoke cigars? (A) No (B) Yes How often? Do you use smokeless tobacco? (A) No (B) Yes How much? Did you ever smoke regularly before? (A) No (B) Yes; packs per day? How many years did you smoke? When did you quit smoking? How much alcohol do you consume in an average week (beer, wine, etc.)? ne B. Less than 6 drinks C. 6-12 drinks D. 12-24 drinks E. 24-48 drinks F. More than 48 drinks What is your current work status? A. Regular employment - no restrictions B. Full time with restrictions C. Part time by choice D. Part time with restrictions E. Part time due to a spine problem F. Part time due to other medical reason, Specify G. Retired by choice H. Retired due to a spine problem I. Retired due to other medical reason, Specify J. Unemployed - looking for work with no restrictions K. Unemployed - looking for light duty work L. Unemployed M. Currently not working due to a spine problem N. Currently not working due to other medical reason, Specify O. Student

8 Do you have a family history of any of these diseases? (Circle all that are appropriate) (31) ne B. Back or neck problems C. Cancer D. Diabetes E. Heart disease F. Hypertension G. Osteoarthritis (wear & tear) H. Rheumatoid arthritis I. Scolio J. Stroke K. Other Have you recently experienced any of the following? General: Weight gain Weight lloss Fever Chills REVIEW OF SYSTEMS Heart: Chest pain Palpitations Fainting Night sweats GU: Frequent urination n: Difficulty with urination Sk Change in moles Blood in urine Breast lumps Vascular: es: Swelling lower extremities Ey Loss of vision Emboli (blood clots) Double vision Musculoskeletal: T: Muscle weakness E Hearing loss Stiffness Nose bleeds Joint pain GI: Psych: Nausea Anxiety Vomiting Depression Change in bowel habits Confusion Heartburn Memory loss Respiratory: Shortness of breath Coughing/wheezing Dr. signature

PREFERRED PHARMACY INFORMATION PATIENT NAME: MR PHARMACY NAME: PHARMACY STREET ADDRESS: CITY,STATE,ZIP PHARMACY CROSS STREETS: PHARMACY PHONE NUMBER: Thank you for taking the time to complete this form on your initial visit. The information provided will assist us in ensuring you receive Florida Orthopaedic Institute's high quality care during your visit with us today. We look forward to keeping you active Everything I have answered is true and correct to the best of my knowledge. Patient Signature: DATE:

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