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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