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





Email Dr. Bitan