Download Spine History Information - Austin Spine Specialists

SPINEHISTORY
Chiefcomplaint□Neck/UpperExtremity(Arm)Pain/Symptoms□Back/LowerExtremity(Leg)Pain/Symptoms
SpinalDeformity(ifknown)□SCOLIOSIS□KYPHOSIS□OTHER_______________________________
Howwasdeformitydiscovered?___________________________CurveMeasurement?(ifknown)___________________
Whendidthepainstart?
Didthepainstart?□gradually□suddenly
Howdiditstart?□AutoAccident□Fall□Lifting
Becauseofthisspineproblem,Ihavefiledorplantofile:
□Bending□Pulling□Twisting□HitinBack
□ALawsuit□AWorker’sCompensationClaim
□Other_____________________________________
□Other___________________________________________
NECK/UPPERExtremity(ARM)Pain/Symptoms
Doyouhavearmpain?□Yes□NoDoyouhavenumbnessinyourarm(s)?□Yes□No
□Left□Right□Both□Left□Right□Both
WhatpercentageisARMpainvs.NECKpain?__________%ARM__________%NECK=100%
WhatpercentageisRIGHTarmpainvs.LEFTarmpain?__________%LEFT__________%RIGHT=100%
BACK/LOWERExtremity(LEG)Pain/Symptoms
DoyouhaveLEGpain?□Yes□NoDoyouhavenumbnessinyourLEG(S)?□Yes□No
□LEFT□RIGHT□BOTH□LEFT□RIGHT□BOTH
WhatpercentageisBACKpainvs.LEGpain?__________%BACK__________%LEG=100%
WhatpercentageisRIGHTLEGpainvs.LEFTLEGpain?__________%RIGHT__________%LEFT=100%
MYPAINIS:
Withcoughorsneeze □BETTER□WORSE□NODIFFERENT
Sitting □BETTER□WORSE□NODIFFERENT
BendingForward □BETTER□WORSE□NODIFFERENT
LyingonBack □BETTER□WORSE□NODIFFERENT
Standing □BETTER□WORSE□NODIFFERENT
HAVEYOUHAD?
NSAIDs □Yes□No□BETTER□WORSE□NODIFFERENT
NarcoticMedications □Yes□No□BETTER□WORSE□NODIFFERENT
MuscleRelaxantMedications □Yes□No□BETTER□WORSE□NODIFFERENT
PhysicalTherapy □Yes□No□BETTER□WORSE□NODIFFERENT
ChiropracticTreatment □Yes□No□BETTER□WORSE□NODIFFERENT
HomeExerciseProgram □Yes□No□BETTER□WORSE□NODIFFERENT
Bracing □Yes□No□BETTER□WORSE□NODIFFERENT
CortisoneInjections □Yes□No□BETTER□WORSE□NODIFFERENT
Whodidtheinjections? Back/NeckSurgery □Yes□No□BETTER□WORSE□NODIFFERENT
Whoperformedthesurgery? HAVEYOUHADANYOFTHEFOLLOWINGFORYOURBACK/NECK?
#OFTIMESDATESDOCTOR/FACILITY
Hospitalization MRI XRays CTScan Myelogram EMG BoneScan Discogram PATIENTNAME_____________________________________DOB____________________DATE___________________
AUSTIN SPINE | 3000 N IH 35, STE. 660| AUSTIN, TX 78705 | PHONE (512)347-7463 | FAX (737)202-2561
MYPAIN/DISCOMFORTLEVELIS(circlenumber)
0 12345678910
(0=NoPainand10=SevereExcruciatingPainasbadasitcouldbe)
Pleasefillinthedrawingbelow:
Usethesymbolsonthediagramsbelowtoshowthetypeofpainyoufeel.
StabbingPain////
Pins&NeedlesVVVV BurningPainOOOO
Numbness-----
AchingPainXXXX
Pleasetakethetimetoreviewthequestionnaireforcompleteness.
____________________________________
SignatureofPatient/LegalGuardian
PATIENTNAME_____________________________________DOB____________________DATE___________________
AUSTIN SPINE | 3000 N IH 35, STE. 660| AUSTIN, TX 78705 | PHONE (512)347-7463 | FAX (737)202-2561