On the day of your appointment we ask that you do not wear any lotion, oil or powder. This may affect the results of the EMG/NCV testing.

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Phone: 907.563.8876 Fax: 907.762.6390 3801 University Lake Drive Anchorage, AK 99508 Dear Patient: Enclosed you will find a questionnaire regarding your past medical history and your current concerns. We ask all our patients to please take the time to complete this questionnaire before your appointment. In the event you are unable to do so, we may need to reschedule your appointment. Please review the pre-appointment instructions prior to your appointment, which is scheduled on at with, at the facility. Please call our office, before your appointment, to preregister. The phone number is (907) 563-8876 or toll free 866-637-3422. On the day of your appointment we ask that you do not wear any lotion, oil or powder. This may affect the results of the EMG/NCV testing. Sincerely, Alaska Spine Institute Providers Larry Levine, MD Michel Gevaert, MD Shawn Johnston, MD Erik Olson, DO Hyon Joo, DO

Electrodiagnostic Testing NAME: DATE: DATE OF BIRTH: AGE: SEX: M F REFERRING PHYSICIAN: WHEN DID YOUR SYMPTOMS BEGIN? IS THIS WORK RELATED? DESCRIBE YOURCOMPLAINTS: SYMPTOMS ARE WORSENED WITH: SYMPTOMS ARE IMPROVED WITH: Rest/Bed Lying down Walking/Standing Time of day Being around people Sexual activity Physical activity Drugs Exercise Other RECENT PRIOR TESTING: TEST WHEN WHERE X-RAYS CT SCAN/ MRI EMG/NCV OTHER PAST MEDICAL HISTORY: Diabetes High blood pressure Hepatitis Thyroid Disease Ulcer Cancer If so what kind? Heart Disease Tuberculosis Lung Disease Kidney Arthritis Depression Other Illnesses Disease Prior Hospitalization: Surgical History ( Procedure and Year): TURN PAGE OVER AND COMPLETE OTHER SIDE

FAMILY HISTORY: Diabetes High blood pressure Cancer If so what kind Heart Disease Depression Disability Chronic pain Stroke Alcoholism Migraine Other SOCIAL HISTORY: Occupation Currently Working? YES NO Smoke: YES NO How much? How Long? Alcohol: YES NO How much? How Long? Marital Status Married Single Divorced Separated Widowed How long? MEDICATIONS: ALLERGIES: YOU MAY USE THE AREA BELOW FOR ANY ADDITIONAL COMMENTS OR INFORMATION THAT YOU FEEL IS IMPORTANT REGARDING YOUR CURRENT MEDICAL CONDITION.

Complete the following diagram drawing the symbols below to show where you have your typical pain /// Ache Numbness Pins and Needles Burning Stabbing /// /// What is your average pain? Or give a range of your level of pain. 0 indicates NO PAIN and 10 indicates pain so severe it would cause you to faint or lose consciousness 0 1 2 3 4 5 6 7 8 9 10

Please review the following list of medical problems and mark any that apply to you now or in the past. Please go over the list carefully. Medical problems that do not seem related to your current situation could result in a serious complication if you do not let us know about them. Constitutional Respiratory Neurologic Recent weight gain: lbs Asthma or wheezing Seizures or convulsions Recent weight loss: lbs Bronchitis Epilepsy Fever or soaking sweats at night Emphysema Stroke Fatigue Pneumonia Brain aneurysm or hemorrhage Weakness/numbness of arms/legs Chronic cough Multiple Sclerosis Headaches 1-2 times per week Change in amount of phlegm Nerve Injury or Numbness Difficulty walking Change in color of phlegm Psychiatric Loss of consciousness/convulsions Coughing up blood Depression Eyes Collapsed lung Anxiety or panic attacks Vision problems not corrected by glasses Tuberculosis exposure Mental disorder Glaucoma Blueness of your fingernails Endocrine Eye lens implant Gastrointestinal Diabetes Eye prosthesis Ulcers Insulin use Contact lenses Hiatal hernia or frequent heartburn Low blood sugar or hypoglycemia Ears, Nose, Throat Ulcerative colitis Thyroid problems Chronic stuffy nose or nasal polyps Diverticulitis Steroid use Frequent nosebleeds Colostomy or other ostomy Allergic/Immunologic Sinus problems Hepatitis or yellow jaundice Herpes exposure Hay fever allergies Liver cirrhosis AIDS exposure Difficulty hearing Gallbladder problems Street drug use Ear infections Vomiting blood Hematologic Hearing aid Black, tarry bowel movements Abnormal bleeding problems Chronic sore throat or tonsillitis Blood in bowel movements Anemia or low blood count Hoarseness Change in bowel habits Blood transfusion Difficulty swallowing Genitourinary Hemophilia Dentures or partial plates Kidney stones Sickle cell anemia Capped teeth Kidney infections Lymphatic Loose teeth Kidney failure Swollen glands or masses in neck, Orthodontic braces Dialysis axillae, groin Cardiovascular Prostate problems Lymphedema Heart murmur Bladder infections Others Prolapsed mitral valve Blood in urine Sexual problems Heart pacemaker Difficulty urinating Muscular dystrophy Irregular heartbeat Do you lose your urine at times Myasthenia gravis Palpitations or rapid pulse Musculoskeletal Malignant hyperthermia Fainting spells Fractures or broken bones Bad reaction to local anesthetic Chest pain or angina on exertion Arthritis Down syndrome Chest pain or angina at night Difficulty opening mouth wide Cancer or tumor Heart attack Scoliosis Chemotherapy Congestive heart failure Spinal column deformity Radiation therapy Swelling in feet or ankles Integumentary/Dermatologic Recent acute illness Shortness of breath lying flat Skin rash or sores Recent hospitalization Shortness of breath at night Itching Recent surgical operation Blood clots or pulmonary embolism Color change, pigmentation, nodules High blood pressure Pressure ulcers Use the back of this page to list Low blood pressure any problems not already covered that you consider important For women only: Are you pregnant? Yes No Number of pregnancies: Are menstrual periods normal? Yes No Number of deliveries: Any vaginal discharge Bleeding between periods Date of last menstrual period: Approx date of last pap smear: Bleeding after menopause I have carefully reviewed this checklist and completed it to the best of my knowledge. Date: Signature of Patient, Parent, or Guardian Relationship to patient, (if not self)

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