ANTHONY W. SHEPLAY, M.D. DOUGLAS T. CANNON, M.D.
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1 1105 Las Tablas Rd., Suite D TEMPLETON, CA Tel: (805) Fax: (805) EIN # ANTHONY W. SHEPLAY, M.D. DOUGLAS T. CANNON, M.D. 620 California Blvd., Suite R SAN LUIS OBISPO, CA Tel: (805) Fax: (805) MUSCULOSKELETAL PAIN QUESTIONNAIRE NAME: AGE: DATE: Welcome. Please take your time and read this questionnaire carefully. Please answer all of the questions. This information will help us treat your problem efficiently, so please take care to be as accurate as possible. Some questions may not apply to your problem, but answer them as best you can. Please Circle your responses unless instructed otherwise. Our goal is to help you improve your health. Thank you. PATIENTS PHARMACY: OFFICE USE BLOOD PRESSURE: PULSE: Page 1
2 Using the symbols given below, mark on the diagram the areas on your body where you feel the described sensations; include all affected areas ( i.e. if the back of your neck hurts, mark the drawing on the back of the neck, etc.). Aching Numbness Pins and needles Burning Stabbing... = = = ooo x x x / / / Page 2
3 1. Date of onset of present pain: 2. Describe how the injury or problem occurred: 3. Is this injury work related:? YES NO Date of Injury: 4. Have you had any of the following studies: Place a check mark next to the ones you brought with you. Date Regular x-ray CT scan EMG Myelogram Bone Scan MRI Findings ( ) ( ) ( ) ( ) ( ) ( ) 5. How would you describe your current pain ratio? ( i.e. if 25% of your pain is in your back and 75% is in your leg, your answer would be letter d.) a. 100% back or neck pain, 0% leg or arm pain. b. 75% back or neck pain, 25% leg or arm pain. c. 50% back or neck pain, 50% leg or arm pain. d. 25% back or neck pain, 75% leg or arm pain. e. 0% back or neck pain, 100% leg or arm pain. 6. Have you recently or are you currently experiencing numbness and / or tingling in your leg, arm, foot or hand? Yes No (circle the correct one). 7. Have you recently or are you currently experiencing weakness in your leg, arm, foot or hand? Yes No (circle the correct one). 8. Have you recently or are you currently experiencing cold or heat in your leg, arm, foot or hand? Yes No ( circle the correct one). 9. Have you had any recent changes in your ability to empty your bowel or bladder (other than constipation)? Yes or No. If Yes, please explain: Page 3
4 10. Read the following scale (#1-10) below and use it to answer questions A through E regarding your pain in recent weeks. 0-No pain. 1-2 Mild pain. 3-5 Moderate pain requiring medications such as Tylenol/aspirin. 6-7 Severe pain causing you to markedly modify your activities and / or take strong medications such as codeine. 8-Intense, so you can barely function. 9-Excruciating so that it is really unbearable. 10-May cause you to think about suicide. A. At its worst B. Most of the time (usual) C. At its best (least) D. In the morning E. Before getting out of bed F. After getting out of bed G. Night time Does the pain keep you awake at night? YES NO 12. How many hours do you sleep? 13. Check which of the following activities that change the nature of your pain: Bending backward Bending forward Coughing/Sneezing Driving Leaning forward Lifting Lying on your back Lying on your side Lying on your stomach Rising from sitting Running Sitting Standing Swimming Walking Walking downhill Walking uphill Other (list): Aggravates Pain Relieves pain (Please circle the most aggravating and the most relieving activity from list above) Page 4
5 14. Answer the next three questions with specific amounts of time (i.e. 5 minutes, 30 minutes, 1 hour, etc.). How long can you sit? Where on your body is your limiting pain? How long can you stand? Where on your body is your limiting pain? How long can you walk? Where on your body is your limiting pain? 15. Using the following list of treatments, please indicate the effect of each in helping to treat your present problem: Helpful Unhelpful Helpful for how long? Acupuncture Brace/Corset Cane/Walker Chiropractor/manipulation Electrical muscle stimulation Epidural injections Facet injections Gravity inversion Hot packs Ice Massage Neck support/collar Press-ups (on stomach) Sit-ups Splint/Orthotics TENS unit Traction Other (list): 16. What is your current treatment program: 17. Are you currently doing a home exercise program? YES NO If yes, please list the exercises and how often they are done: Page 5
6 OSWESTRY FUNCTION TEST Please Circle the one answer in each section that best applies to your condition. SECTION 1: PAIN INTENSITY 1. I can tolerate my pain without having to use pain killers. 2. My pain is bad but I manage without taking pain killers. 3. Pain killers give me complete relief from my pain. 4. Pain killers give me moderate relief from my pain. 5. Pain killers give me very little relief from my pain. 6. Pain killers have no effect on my pain and I do not use them. SECTION 2: PERSONAL CARE (washing, dressing, etc.) 1. I can look after myself normally without causing extra pain. 2. I can look after myself normally but it causes extra pain. 3. It is painful to look after myself and I am slow and careful. 4. I need some help but I manage most of my personal care. 5. I need help everyday in most aspects of self care. 6. I do not get dressed, wash with difficulty, and stay in bed. SECTION 3: LIFTING 1. I can lift heavy objects without extra pain. 2. I can lift heavy objects but it gives me extra pain. 3. Pain prevents me from lifting heavy objects off the floor, but I can manage if they are conveniently positioned. 4. Pain prevents me from lifting heavy objects, but I can manage light to medium objects if they are conveniently positioned. 5. I cannot lift or carry anything at all. SECTION 4: WALKING 1. Pain does not prevent me from walking any distance. 2. Pain prevents me from walking more than 1 mile. 3. Pain prevents me from walking more than 1/2 mile. 4. Pain prevents me from walking more than 1/4 mile. 5. I can only walk using a cane or crutches I am in bed most of the time and have to crawl to the toilet. SECTION 5: SITTING 1. I can sit in any chair for as long as I like it. 2. I can only sit in my favorite chair as long as I like it. 3. Pain prevents me from sitting more than 1 hour. 4. Pain prevents me from sitting more than ½ hour. 5. Pain prevents me from sitting more than 10 minutes. 6. Pain prevents me from sitting at all. Page 6
7 SECTION 6: STANDING 1. I can stand for as long as I want without extra pain. 2. I can stand for as long as I want, but it gives me extra pain. 3. Pain prevents me from standing more than 1 hour. 4. Pain prevents me from standing more than ½ hour. 5. Pain prevents me from standing more than 10 minutes. 6. Pain prevents me from standing at all. SECTION 7: SLEEPING 1. Pain does not prevent me from sleeping well. 2. I can sleep well only by taking medications for sleep. 3. Even when I take medication, I have less than 6 hours of sleep. 4. Even when I take medication, I have less than 4 hours of sleep. 5. Even when I take medication, I have less than 2 hours of sleep. 6. Pain prevents me from sleeping at all. 1. My sex life is normal and causes me no extra pain. 2. My sex life is normal but causes some extra pain. 3. My sex life is nearly normal but is very painful. 4. My sex life is severely restricted by pain. 5. My sex life is nearly absent because of pain. 6. Pain prevents any sex life at all. SECTION 8: SEX LIFE SECTION 9: SOCIAL LIFE 1. My social life is normal and gives me no extra pain. 2. My social life is normal but increases the degrees of pain. 3. Pain has no significant effect on my social life apart from limiting my more energetic interests like dancing. 4. Pain has restricted my social life and I do not go out as often. 5. Pain has restricted my social life to my home. 6. I have no social life because of pain. SECTION 10: TRAVEL 1. I can travel anywhere without extra pain. 2. I can travel anywhere but it gives me extra pain. 3. Pain is bad but I manage journeys over 2 hours. 4. Pain restricts me to journeys of less than 1 hour. 5. Pain restricts me to short, necessary journeys under 1/2 hour. 6. Pain prevents me from traveling except to the doctor or hospital. Page 7
8 MEDICAL INFORMATION NAME: AGE: HEIGHT: WEIGHT: How many pounds has your weight changed since your injury? ALLERGIES: List all medications and foods to which you are allergic and describe the reaction: Medications/Food Reaction CURRENT MEDICATIONS: (list all medications dosage and frequency) Medication Strength (mg) Frequency Medication Strength (mg) Example: Aspirin 81mg 1 tab daily Frequency PAST MEDICATIONS: Include any medications you have used for pain and by those that have been helpful. Medication Strength (mg) Frequency Medication Strength (mg) Frequency MEDICAL HISTORY: (check all that apply to you) Anxiety/Panic Attacks Arthritis (type) Asthma Blood or Bleeding Disorders Cancer: (type) Complication of Anesthesia Depression Diabetes Emphysema Head Injury/Concussion Heart Attack Heart Disease Hepatitis/liver disease Hypertension/High Blood Pressure High Cholesterol Lupus Kidney Stones Migraines Osteoporosis/osteopenia Parkinson s Phlebitis or Blood Clots Polio Prostate Problems Seizure Schizophrenia Sleep Apnea Stroke Stomach Ulcers Thyroid Disease Tuberculosis Valley Fever Other: List other medical conditions and/or illnesses not mentioned above: Page 8
9 PAST SURGICAL HISTORY Surgery Date Surgery Date Have you had injections previously for current problem? YES NO What type? INJURIES Injury Date FAMILY HISTORY: List the family member next to the condition and do no include yourself Arthritis: Autoimmune Disease: Back Pain: Cancer: Chronic Pain: Depression: Diabetes: Drug Abuse: SOCIAL HISTORY: (Circle present status) Headaches Heart Disease: Kidney Disease: Liver Disease: Psychiatric Disorder: Sexual Abuse: Stroke: Other: Married: how long? Divorced Separated Widowed Single Spouse s health problems: Children s age: Number living in home: Education-highest grade: Degree: Do you have a religious belief or affiliation? YES NO If yes, which one? On a 1-10 scale, 10 being strong, how strong is your faith? Page 9
10 Hobbies, vocational activities: To what activities (sports, hobbies) do you hope to return? What are your favorite activities? Smoking: YES NO Have you ever Smoked: YES NO No. Packs per day? Number of years? Previously Quit Date: Drinking: YES NO Amount: Heavy in the past? Any history of recreational drug/substance use? Prior YES NO Current: YES NO If yes, list drugs: Have you ever been (circle) sexually, physically, emotionally abused? YES NO WORK HISTORY Occupation: Employer: Full-time Part-Time Retired: Student Homemaker Student Unemployed: Last date worked: How much of your working day do you spend? Estimate hours per day. Sitting Lifting Walking Driving Lifting: Weight of Objects: Lifting Frequency : Legal Issues: Please indicate any of the following claims you have filed related to your pain problem: Worker s compensation Personal Injury/Liability Social Security Other Disability: Applying for Disability: Y N Applying for Social Security: Y N Describe your required work tasks for a typical day (i.e. what you do, equipment used, objects handled, lifted or moved, etc.): How much time from work have you missed in the past year? Do you have a lawyer for your injury? YES NO If yes, Name: Is there upcoming litigation? YES NO Is there an upcoming Workman s Compensation hearing? YES NO If this problem is work related, have you been placed at Permanent and Stationary status? YES NO If yes, by what doctor? Page 10
11 Do you have a prior history of a work injury for which you were out of work or received workers compensation payments? YES NO If yes, please list the injury(s), when it occurred (date), and how long you received compensation payments or were out of work for that problem. List all prior work related injuries: Have you been pleased with the medical care you have received up to this point? YES NO How do you like your present (or last) job? Circle one (Very little) (Very much) Do you feel that your supervisor/employer is sensitive to your present problem? YES NO Would you like to work in a different occupation? YES NO If yes, which one? PAST WORK HISTORY What type of work have you done in the past before your present job? (List most recent 3 jobs and dates worked) REVIEW OF SYSTEMS(Circle applicable symptoms and describe and/or add others if needed) Constitutional: fever, weight gain/loss, loss of appetite Eyes: double vision, blurring, difficulty seeing ENT: deafness, sinusitis, hoarseness, vertigo Cardiovascular: chest pain, palpitations, irregular/rapid heart beats, murmur Respiratory: shortness of breath, wheezing, spitting blood, chronic cough Digestive: abdominal pain, constipation, diarrhea, bleeding Urologic: pain when urinating, hesitancy, bleeding, incontinence Gynecologic: breast masses, pain, discharge Skin: Rashes, lesions that do not heal, changes in moles Neurologic: seizures, loss of balance/coordination, paralysis, weakness, loss of memory Page 11
12 Psychiatric: Depression, anxiety, hallucinations, sleep disturbances Endocrine: excessive thirst, excessive urination, heat/cold intolerance Blood and Lymph: Anemia, bleeding tendencies, swollen nodes Allergic and Immunologic: Hives, eczema, itching Musculoskeletal: stiffness, joint pain/deformity, muscle wasting, spine pain radiating to arm/leg Other: List all physicians and chiropractors that you have consulted for your present problem: Please provide any additional information that you feel is important. Patient Signature Date Page 12
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