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Oregon Spine Care
New Patient Questionnaire
Name:____________________________________ Birth Date:_______________________________
Chief Complaint: ___________________________________________________________________
When did your spine problem first begin? ________________________________________________
Did your pain start because of an:
Accident at work
Motor vehicle accident
If there was an accident, what caused the pain ._____________________________________________
Workers Compensation Claim? [ ] Yes
[ ] No
Do you have any problems controlling your bowel and / or bladder? [ ] Yes [ ] No
Hand dominance:
Right
Left
Mark the areas of your body where you feel pain, numbness or weakness. Use the appropriate
symbol.
Numbness or pins/needles
Aching or cramping
Muscle weakness
Right
OOOOOOOOOOO
XXXXXXXXXXXXX
++++++++++++++
Left
Left
Right
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NEW NECK PAIN: Circle all those that apply
Chief Complaint:
Neck
Headache
Right Shoulder Left Shoulder
Overall Neck Pain: 1…2…3…4…5…6…7…8…9…10
Right Upper Extremity
Left Upper Extremity
Overall Upper Extremity Pain: 1…2…3…4…5…6…7…8…9…10
Neck pain: choose most applicable:
Neck pain > Upper extremity pain
Upper extremity pain > neck pain
NECK PAIN
Aching
Burning
Stabbing
Throbbing
Tingling
ARM PAIN QUALITY
Aching
Burning
Stabbing
Throbbing
Tingling
Constant
Intermittent
Constant
Intermittent
Gradually Worsening
Rapidly Worsening
Gradually Improving
Rapidly Improving
Gradually Worsening
Rapidly Worsening
Gradually Improving
Rapidly Improving
Upper extremity pain = neck pain
NUMBNESS
None
Right Shoulder
Right Arm
Right Forearm
Right Thumb
Right Long Finger
Right Small Finger
WEAKNESS
None
Right Shoulder
Right Arm
Right Forearm
Right Thumb
Right Long Finger
Right Small Finger
Left Shoulder
Left Arm
Left Forearm
Left Thumb
Left Long Finger
Left Small Finger
Left Shoulder
Left Arm
Left Forearm
Left Thumb
Left Long Finger
Left Small Finger
NEW BACK PAIN: Circle all those that apply
Chief Complaint:
Mid-Back
Low Back
Sacrum Right Buttock
Overall Back Pain: 1…2…3…4…5…6…7…8…9…10
Left Buttock
Right Lower Extremity
Left Lower Extremity
Overall Lower Extremity Pain: 1…2…3…4…5…6…7…8…9…10
Back pain: choose most applicable:
Back pain > lower extremity pain
Lower extremity pain > back pain
BACK PAIN QUALITY
Aching
Burning
Stabbing
Throbbing
Tingling
LEG PAIN QUALITY
Aching
Burning
Stabbing
Throbbing
Tingling
Constant
Intermittent
Constant
Intermittent
Gradually Worsening
Rapidly Worsening
Gradually Improving
Rapidly Improving
Gradually Worsening
Rapidly Worsening
Gradually Improving
Rapidly Improving
The symptoms are better with:
The symptoms are worse with
Rest
Bending forward
Lower extremity pain = back pain
NUMBNESS
Left Buttock
Left Anterior Thigh
Left Knee
Left Shin
Left Top of Foot
Left Bottom of Foot
WEAKNESS
Left Buttock
Left Hip
Left Thigh
Left Ankle
Left Big Toe
Left Calf
Right Buttock
Right Anterior Thigh
Right Knee
Right Shin
Right Top of Foot
Right Bottom of Foot
Right Buttock
Right Hip
Right Thigh
Right Ankle
Right Big Toe
Right Calf
Lying down
Bending backward
Bending forward
Bending backward
Sitting
Standing/Walking
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Name:____________________________________ Birth Date:_______________________________
Treatments
Physical Therapy
[ ] never tried
[ ] helpful [ ] not helpful
Last treatment _____________ Where_______________ Dates______________
What treatment was performed? [ ] exercises [ ] stretching [ ] TENS unit [ ] ultrasound [ ]massage
Spine Injections
[ ] never tried
[ ] helpful [ ] not helpful
Last treatment _____________ Where_______________ Dates______________
Acupuncture
[ ] never tried
[ ] helpful [ ] not helpful
Last treatment _____________ Where_______________ Dates______________
Chiropractics
[ ] never tried [ ] helpful [ ] not helpful
Last treatment _____________ Where_______________ Dates______________
Oral Steroids
[ ] never tried [ ] helpful [ ] not helpful
Last treatment _____________ Where_______________ Dates______________
REVIEW OF SYSTEMS
Are you having any of these symptoms/conditions today
Constitutional/General
Fever
[ ] Yes [ ] No
Chills
[ ] Yes [ ] No
Neurologic
Headache
Seizures
[ ] Yes [ ] No
[ ] Yes [ ] No
Ears/Nose/Mouth/Throat
Dizziness
[ ] Yes [ ] No
Difficulty Swallowing
[ ] Yes [ ] No
Cardiovascular
Chest Pain
Irregular Heart beat
[ ] Yes [ ] No
[ ] Yes [ ] No
Endocrine
Diabetes
Fatigue
[ ] Yes [ ] No
[ ] Yes [ ] No
Psychiatric
Depression
Anxiety
[ ] Yes [ ] No
[ ] Yes [ ] No
Gastrointestinal
Ulcers
GERD
[ ] Yes [ ] No
[ ] Yes [ ] No
Genitourinary
Urgent urination
Frequent urination
[ ] Yes [ ] No
[ ] Yes [ ] No
Pulmonary
Shortness of Breath
Asthma
[ ] Yes [ ] No
[ ] Yes [ ] No
Hematologic/Lymphatic
Anemia
[ ] Yes [ ] No
Bleeding Problem
[ ] Yes [ ] No
Please list any spine surgeries [ ] NONE
Lumbar
1
2
Type of Surgery
Cervical
1
2
Type of Surgery
Date
Date
Surgeon
Surgeon
Helpful
Yes No
Yes No
Helpful
Yes No
Yes No
SX
SX
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Name:____________________________________ Birth Date:_______________________________
Medications – Attach sheet if necessary [ ] Check if No Medications
Medication
Strength/Directions
Allergies– Attach sheet if necessary [ ] Check if No known drug allergies
Medication/Allergies
Reaction
MEDICAL HISTORY
Please check the box if you have any of the following conditions:
[] Anxiety
[] Cancer
[] Heart Disease
[] Multiple Sclerosis
[] Arthritis
[] Depression
[] High Blood Pressure
[] Osteoporosis
[] Asthma
[] Diabetes
[] High Cholesterol
[] Seizures
[] Blood Disorder
[] Epilepsy
[] Kidney Disease
[] Stroke
Height __________________________________________ Weight _______________________________
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Name:____________________________________ Birth Date:_______________________________
FAMILY HISTORY
Please check the box if anyone in your immediate family has had any of the following conditions:
(NOTE RELATIONSHIP PLEASE Specify maternal/paternal for grandparents ie: maternal grandfather)
[] Anxiety ____________
[] Blood Disorder ____________
[] Diabetes ____________
[] High Blood Pressure ____________
[] Arthritis ____________
[] Cancer ____________
[] Epilepsy ____________
[] High Cholesterol ___________
[] Asthma____________
[] Depression ________
[] Heart Disease ___________
[]Kidney Disease __________
[] Multiple Sclerosis ____________
[] Osteoporosis ____________
[] Seizures ____________
SOCIAL HISTORY
Current Marital Status:
[ ] Married [ ] Single [ ] Divorced [ ] Widowed [ ]Partner
Living Status:
[ ] alone [ ] with spouse [ ] with parents [ ] with roommate [ ] assisted living [ ] nursing home
Current Occupation:______________________________
Highest education level: [ ] Grade School [ ] Middle School [ ] High School [ ] College [ ] Post Graduate
Do you use tobacco now or in the past?
[ ] Yes, use now [ ] Never used [ ] Previous user
Cigarettes How many per day? _________ How many years? ___________
Cigars
How many per day? _________ How many years? ___________
Do you drink alcoholic beverages? [ ] Never
[ ] Weekly
Have you ever felt the need to cut down on drinking?
Have you ever felt annoyed by criticism of your drinking?
Have you ever felt guilty about your drinking?
Have you ever felt the need for a morning eye-opener?
[ ] 1-2 x week
[
[
[
[
] Yes [
] Yes [
] Yes [
] Yes [
[ ] 3 x week
] No
] No
] No
] No
Have you tried illicit drugs? [ ] Yes, use now [ ] Never used [ ] Previous user
substance?_____________________
What was the
Please check / list all operations: [ ] none
[
[
[
[
[
[
[
] Appendectomy
] Tonsillectomy
] Gall bladder removal
] Knee arthroscopy
] Knee replacement
] Hip replacement
] _______________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
[ ] Eye Surgery
[ ] Heart surgery
[ ] Hysterectomy
[ ] Prostate surgery
[ ] Surgery for cancer
[ ] _______________
[ ] _______________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
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