preparing for a visit
_____/_____/_____
Date
Last Name First Name
WHO REFERRED YOU TO THE SPINE CENTER:
Name Telephone Number
Address
PLEASE PUT AN "X" NEXT TO THE BEST ANSWER FOR EACH QUESTION
RACE:
___ WHITE __ BLACK ___ INDIAN ___ ASIAN
___ HISPANIC __ OTHER
SEX: ___ MALE ___ FEMALE
AGE: DATE OF BIRTH _____/_____/_____
MARITAL STATUS:
___ SINGLE ___ MARRIED ___ REMARRIED
___ DIVORCED ___ WIDOWED ___ SEPARATED
EDUCATION: HIGHEST YEAR COMPLETED
___ ( 0 1 2 3 4 5 6 7 8 ) GRADE SCHOOL
___ ( 9 10 11 12 ) HIGH SCHOOL
___ ( 13 14 15 16 ) COLLEGE, TECHNICAL
___ ( > 16 YEARS ) GRADUATE, PROFFESIONAL
OCCUPATION
DO YOU HAVE
___ ONLY BACK PAIN
___ ONLY LEG PAIN
___ BACK AND LEG PAIN
___ ONLY NECK PAIN
___ ONLY SHOULDER / ARM PAIN
___ NECK, SHOULDER AND ARM PAIN
___ OTHER
WHICH IS WORSE:
___ BACK PAIN ___ LEG PAIN (RIGHT LEFT)
___ NECK PAIN ___ SHOULDER / ARM PAIN (RIGHT LEFT)
MY PAIN NOW SEEMS TO BE:
___ GETTING BETTER ___ STAYING THE SAME
___ GETTING WORSE
I HAVE HAD BACK / NECK PAIN:
___ LESS THAN 1 MONTH ___ 1 - 3 MONTHS
___ 3 - 6 MONTHS ___ 6 MONTHS - 1 YEAR
___ 1 - 3 YEARS ___ 3 - 5 YEARS
___ GREATER THAN 5 YEARS
MY PAIN CAME ON:
___ GRADUALLY, OVER TIME ___ QUICKLY
MY PAIN WAS BROUGHT ON BY:
___ NO SPECIFIC INCIDENT
___ FOLLOWING AN ACCIDENT OR INCIDENT AT WORK
___ FOLLOWING AN ACCIDENT OR INCIDENT NOT AT WORK
DESCRIBE THE ACCIDENT / INCIDENT:
DO YOU HAVE:
___ NUMBNESS WHERE
___ TINGLING WHERE
___ WEAKNESS WHERE
WHAT TIME OF THE DAY IS YOUR PAIN WORSE:
___ MORNING
___ LATE IN THE DAY
___ THE MIDDLE OF THE NIGHT
HOW FAR CAN YOU WALK:
___ LESS THAN 15 MINUTES ___ 15 - 30 MINUTES
___ 30 - 60 MINUTES ___ NO RESTRICTIONS
HOW LONG CAN YOU SIT:
___ LESS THAN 15 MINUTES ___ 15 - 30 MINUTES
___ 30 - 60 MINUTES ___ NO RESTRICTIONS
HOW LONG CAN YOU STAND:
___ LESS THAN 15 MINUTES ___ 15 - 30 MINUTES
___ 30 - 60 MINUTES ___ NO RESTRICTIONS
WHAT MAKES YOUR PAIN BETTER OR DECREASED:
___ BEDREST ___ SITTING
___ MEDICATION ___ COLD / HEAT
___ NOTHING
___ OTHER
ON A SCALE OF 0 (NO PAIN) TO 10 (THE WORSE PAIN EVER), HOW WOULD
YOU RATE YOUR PAIN TODAY:
0 1 2 3 4 5 6 7 8 9 10
WHERE HAVE YOU SOUGHT HELP FOR YOUR PAIN: (CHECK ALL THAT APPLY)
___ FAMILY DOCTOR ___ PHYSICAL THERAPIST
___ CHIROPRACTOR ___ ORTHOPEDIC DOCTOR
___ NEUROLOGIST ___ PAIN CLINIC
___ ANOTHER SPINE SURGEON ___ PSYCHIATRIST / PSYCHOLOGIST
___ OTHER
HAVE YOU NOTICED A CHANGE IN YOUR BOWEL OR BLADDER HABITS:
___ NO ___ YES DESCRIBE:
ARE YOU CURRENTLY :
___ WORKING FULL TIME ___ WORKING PART TIME
___ UNEMPLOYED ___ RETIRED
___ DISABLED, TEMPORARILY ___ DISABLED, PERMANENTELY
___ HOUSEWIFE
___ OTHER
IF YOU ARE CURRENTLY NOT WORKING, HOW MANY MONTHS HAVE
YOU BEEN UNABLE TO WORK BECAUSE OF YOUR BACK / NECK PAIN:
HAVE YOU, OR ARE YOU PLANNING TO APPLY FOR DISABILITY
OR WORKMENıS COMPENSATION?
___ YES ___ NO
IS THERE A LAWSUIT OR LITIGATION PENDING IN RELATIONSHIP
TO YOUR BACK PROBLEM?
___ YES ___ NO
MEDICINE / SUBSTANCE ALLERGIES:
___ NONE
CURRENT MEDICATIONS:
___ NONE
CURRENT/PAST HEALTH PROBLEMS:
___ HEART DISEASE ___ HIGH BLOOD PRESSURE
___ DIABETES ___ ASTHMA
___ KIDNEY DISEASE ___ TUBERCULOSIS
___ MIGRAINE HEADACHES ___ HEPATITIS
___ EPILEPSY ___ EMOTIONAL DISORDER
___ CANCER ___ HIV
___ OTHER ___ NONE
DO YOU SMOKE CIGARETTES: ___ NO ___ YES PACKS PER DAY
DO YOU CONSUME ALCOHOL: ___ NO ___ YES GLASSES PER WEEK
HAVE YOU HAD PREVIOUS SURGERY:
___ YES WHEN: ____/____/____ TYPE:
___ NO ____/____/____ TYPE:
____/____/____ TYPE:
____/____/____ TYPE:
SCOLIOSIS / KYPHOSIS SECTION
YEAR DEFORMITY WAS FIRST NOTICED: 19______
YOUR AGE AT TIME DEFORMITY WAS FIRST NOTICED: ________
FAMILY HISTORY OF SCOLIOSIS / KYPHOSIS:
___ NONE
___ PARENT
___ BROTHER / SISTER
___ COUSIN
___ OTHER
PREVIOUS NON-OPERATIVE TREATMENT:
___ NONE
___ EXERCISE
___ BRACE
___ OBSERVATION ONLY
___ OTHER
FIRST OPERATION: _____/_____/_____
SECOND OPERATION: _____/_____/_____
CURRENT CONCERNS:
___ NONE
___ FEEL IMBALANCED
___ NEW OR INCREASED BACK PAIN
___ PAINFUL ROD
___ UNHAPPY WITH MY APPEARANCE
IF YOU HAVE BACK PAIN, SITE:
___ UPPER BACK ___ MID BACK ___ LOWER BACK
DO YOU FEEL THAT YOUR CURVES HAVE INCREASED OVER TIME:
___ YES ___ NO
DO YOU FEEL YOU HAVE LOST HEIGHT IN THE PAST FEW YEARS:
___ YES ___ NO
END, THANK YOU
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