Download The Spine Center Patient Information

The Spine Center
Patient Information
Date:___________________________
LAST NAME
FIRST NAME
DATE OF BIRTH
PRIMARY CARE PHYSICIAN
PHONE NUMBER
REFERRING PHYSICIAN OR OTHER REFERENCE
PHONE NUMBER
CURRENT AGE
Reasons for Visit
■ Work comp injury
■ Automobile accident
PRIMARY REASON FOR THIS VISIT
■ Other injury
(describle location of pain)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Factors of Complaint
Explain how your pain or problem began and how it happenned
■ Recent injury
■ On-the-job
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
How long have you had this problem? __________________________________________________________________________________
________________________________________________________________________________________________________________
Ortho Pain Chart
Mark the areas on your body where you feel the described
R
sensations using the appropriate symbol from the list below.
L
L
R
Please include all affected areas.
numbness
===
pins & needles
ooo
burning/aching
xxx
stabbing
///
FOR OFFICE USE ONLY
DX:
PLAN:
PATIENT INITIALS
DATE
1
The Spine Center
Patient Information
Current Pain Profile
WHICH OF THE FOLLOWING ACTIVITIES CHANGE THE NATURE OF YOUR PAIN
Sitting
■ Aggravates pain
■ Relieves pain
■ Neither
Standing
■ Aggravates pain
■ Relieves pain
■ Neither
Walking
■ Aggravates pain
■ Relieves pain
■ Neither
Long car rides
■ Aggravates pain
■ Relieves pain
■ Neither
Bending forward
■ Aggravates pain
■ Relieves pain
■ Neither
LIST ANYTHING ELSE THAT DECREASES OR INCREASES YOUR PAIN
(ex. temperature changes, laughing, using the restroom, etc.):
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Functional History
PLEASE INDICATE THE ACTIVITIES THAT YOU REQUIRE ASSISTANCE PERFORMING :
■ Driving
■ Bathing
■ Household chores (laundry, dishes, vacuuming, etc.)
■ Walking
■ Using the washroom
■ Outdoor yard work (mowing lawns, trimming hedges, raking, gardening, etc.)
■ Standing
■ Dressing
■ Buttoning shirt
■ Ambulating up or down stairs
■ Shopping
Do you frequently drop things? ■ Yes ■ No
■ Lifting
■ Writing
■ Dropping objects
■ Cooking
■ Ambulating
PREVIOUS TREATMENTS FOR THIS CONDITION
Medications
Anti-inflammatories____________________________________
■ Temporary relief
■ Lasting relief
■ No relief
Muscle relaxants ______________________________________
■ Temporary relief
■ Lasting relief
■ No relief
Pain medications ______________________________________
■ Temporary relief
■ Lasting relief
■ No relief
Other(s)_____________________________________________
■ Temporary relief
■ Lasting relief
■ No relief
Chiropractic care ______________________________________
■ Temporary relief
■ Lasting relief
■ No relief
Physical therapy_______________________________________
■ Temporary relief
■ Lasting relief
■ No relief
Other(s)_____________________________________________
■ Temporary relief
■ Lasting relief
■ No relief
Date_________________ Injection type______________________
■ Temporary relief
■ Lasting relief
■ No relief
Date_________________ Injection type______________________
■ Temporary relief
■ Lasting relief
■ No relief
Therapies
Injections
(i.e. epidural steroid injections, nerve-root blocks)
Previous treating doctors
__________________________________________________________________________________________
Specialty(s) (i.e. surgeon) ___________________________________________________________________________________________
Spine Surgery ____________________________________________________________________________________________________
_______________________________________________________________________________________________________________
PATIENT INITIALS
DATE
2
The Spine Center
Patient Information
Family History
WHAT ILLNESSES RUN IN YOUR CLOSE FAMILY
■ Scoliosis
■ High blood pressure
■ Mental illness
■ Spine disease
■ Diabetes
■ Alcoholism
■ Arthritis
■ Cancer
■ Kidney disease
■ Heart disease
■ Bleeding disorder
■ Other
Medical History
PLEASE CHOOSE ALL CURRENT
& PAST
MEDICAL CONDITIONS
■ No medical problem
■ Emphysema
■ Tuberculosis
■ Ovarian cysts
■ High blood pressure
■ Liver disease
■ Kidney failure
■ Anxiety
■ Heart attack
■ Hepatitis
■ Kidney stones
■ Depression
■ Heart failure
■ Diabetes
■ Osteoporosis
■ Schizophrenia
■ Abnormal heart rhythm
■ Thyroid disease
■ Osteoarthritis
■ Anorexia/bulimia
■ Lung disease
■ Stomach ulcers
■ Rheumatoid arthritis
■ Alcoholism
■ Cancer where? ________________
■ Irritable bowel
■ Bleeding disorders
■ Seen a psychiatrist
■ Asthma
■ Stroke
■ Blood clots in leg/lung
■ HIV
■ Bronchitis
■ Seizures
■ Endometriosis
■ Sleep apnea
■ Elevated cholesterol
■ Parkinsons
■ Multiple sclerosis
■ RSD
■ Fibromyalgia
■ Chronic Pain
■ Chronic Fatigue
Are you under a doctor’s care for any other medical condition
■ Yes
■ Use CPAP
■ No
If yes, please explain ______________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Surgical History
PLEASE CHOOSE ALL SPINAL SURGERIES YOU HAVE HAD
■ Other ______________
Type of surgery ____________________________________________________
Date(s) ____________________
■ Back _______________
Type of surgery ____________________________________________________
Date(s) ____________________
Type of surgery ____________________________________________________
Date(s) ____________________
______________________________________________________________________________________________________________________
Social History
■ Married
■ Divorced
Number of children___________
■ Yes
■ No
■ Separated
■ Single
■ Widow/Widower
■ At home
■ Away
Other dependents__________
I live with my children or other relatives (Explain)__________________________________________________________
Do you drink?
■ Yes
I drink
■ Beer
■ Wine
■ “Hard” drinks
Frequency
■ Rarely
■ Socially
■ Daily
Do you smoke?
■ Yes
■ Smokeless/leaf
■ No
■ No
I smoke
■ Cigarettes
■ Cigar/pipe
Frequency
Per day______
Years______
I quit
When______
______
PATIENT INITIALS
DATE
3
The Spine Center
Patient Information
Review of Systems
PLEASE CHECK OFF ANY CURRENT OR RECENT PROBLEMS YOU HAVE
General
Skin
Genitourinary
■ Unexplained weight loss
■ Easy bruising
■ Burning on urination
■ Appetite change
■ Swollen ankles
■ Difficulty starting urination
■ Fevers or chills
■ Incontinence (stress)
Lung
■ Night sweats
■ Pelvic pain
■ Morning cough
■ Marked fatigue
■ Urinate at night more than once
■ Shortness of breath
■ Difficulty sleeping
■ Productive cough or sputum
Cardiovascular
Psychiatric
Neurological
■ Heart or chest pain
■ Depression
■ Seizures
■ Abnormal heartbeat
■ Nervous exhaustion
■ Blackouts/fainting
■ Poor heart function
■ Anxiety
■ Tremor
Musculoskeletal
■ Headaches/migraines
■ Joint pain/swelling
■ Loss of balance
■ Back pain
■ Increased clumsiness
■ Unable to completely empty bladder
■ Paranoia
■ Obsessive/compulsive behavior
■ History of sexual abuse
■ History of physical abuse
■ Neck pain
■ Muscle aches
Other:_________________________
______________________________
Digestive
______________________________
■ Nausea or vomiting
■ Stomach pain or ulcers
■ Heartburn/acid stomach
■ Frequent diarrhea
■ Frequent constipation
■ Uncontrolled loss of stool
■ Blood in stool
Work History
Employment status:
■ Full time
■ Part time
■ Self employed
■ Disabled
■ Retired
■ Unemployed
Last date of employment:________________________________
I work as a ____________________________________ Previous occupations(s)_______________________________________________
Describe job duties: _______________________________________________________________________________________________
■ Yes
■ No
Do you have any lawsuits pending?
■ Yes
■ No
Are you considering filing a lawsuit regarding this problem?
■ Yes
■ No
Do you have any workman’s compensation claims pending?
■ Yes
■ No
Have you ever had any past workman’s compensation claims?
PATIENT INITIALS
DATE
4