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
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1 New Patient Questionnaire Oregon Spine Care 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? 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 O O O O O O O O O O O Aching or cramping X X X X X X X X X X X X X Muscle weakness Right Left Left Right Page 1 of 6
2 NEW NECK PAIN: Circle all those that apply Chief Complaint: Neck Headache Right Shoulder Left Shoulder Right Upper Extremity Left Upper Extremity Overall Neck Pain: Overall Upper Extremity Pain: Neck pain: choose most applicable: Neck pain > Upper extremity pain Upper extremity pain > neck pain Upper extremity pain = neck pain NECK PAIN ARM PAIN QUALITY NUMBNESS WEAKNESS Aching Aching None None Burning Burning Right Shoulder Right Shoulder Stabbing Stabbing Right Arm Right Arm Throbbing Throbbing Right Forearm Right Forearm Tingling Tingling Right Thumb Right Thumb Right Long Finger Right Long Finger Constant Constant Right Small Finger Right Small Finger Intermittent Intermittent Left Shoulder Left Shoulder Left Arm Left Arm Gradually Worsening Gradually Worsening Left Forearm Left Forearm Rapidly Worsening Rapidly Worsening Left Thumb Left Thumb Gradually Improving Gradually Improving Left Long Finger Left Long Finger Rapidly Improving Rapidly Improving Left Small Finger Left Small Finger NEW BACK PAIN: Circle all those that apply Chief Complaint: Mid-Back Low Back Sacrum Right Buttock Left Buttock Right Lower Extremity Left Lower Extremity Overall Back Pain: Overall Lower Extremity Pain: Back pain: choose most applicable: Back pain > lower extremity pain Lower extremity pain > back pain Lower extremity pain = back pain BACK PAIN QUALITY LEG PAIN QUALITY NUMBNESS WEAKNESS Aching Aching Left Buttock Left Buttock Burning Burning Left Anterior Thigh Left Hip Stabbing Stabbing Left Knee Left Thigh Throbbing Throbbing Left Shin Left Ankle Tingling Tingling Left Top of Foot Left Big Toe Left Bottom of Foot Left Calf Constant Constant Intermittent Intermittent Right Buttock Right Buttock Right Anterior Thigh Right Hip Gradually Worsening Gradually Worsening Right Knee Right Thigh Rapidly Worsening Rapidly Worsening Right Shin Right Ankle Gradually Improving Gradually Improving Right Top of Foot Right Big Toe Rapidly Improving Rapidly Improving Right Bottom of Foot Right Calf The symptoms are better with: Rest Lying down Bending forward Bending backward The symptoms are worse with Bending forward Bending backward Sitting Standing/Walking Page 2 of 6
3 Name: Birth Date: Treatments Physical Therapy [ ] never tried [ ] helpful [ ] not helpful What treatment was performed? [ ] exercises [ ] stretching [ ] TENS unit [ ] ultrasound [ ]massage Spine Injections [ ] never tried [ ] helpful [ ] not helpful Acupuncture [ ] never tried [ ] helpful [ ] not helpful Chiropractics [ ] never tried [ ] helpful [ ] not helpful Oral Steroids [ ] never tried [ ] helpful [ ] not helpful Are you having any of these symptoms/conditions today REVIEW OF SYSTEMS Constitutional/General Neurologic Fever Headache Chills Seizures Ears/Nose/Mouth/Throat Cardiovascular Dizziness Chest Pain Difficulty Swallowing Irregular Heart beat Endocrine Psychiatric Diabetes Depression Fatigue Anxiety Gastrointestinal Genitourinary Ulcers Urgent urination GERD Frequent urination Hematologic/Lymphatic Pulmonary Anemia Shortness of Breath Bleeding Problem Asthma Please list any spine surgeries [ ] NONE Lumbar Type of Surgery Date Surgeon Helpful SX 1 Yes No 2 Yes No Cervical Type of Surgery Date Surgeon Helpful SX 1 Yes No 2 Yes No Page 3 of 6
4 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 [] Arthritis [] Asthma [] Blood Disorder [] Cancer [] Depression [] Diabetes [] Epilepsy [] Heart Disease [] High Blood Pressure [] High Cholesterol [] Kidney Disease [] Multiple Sclerosis [] Osteoporosis [] Seizures [] Stroke Height Weight Page 4 of 6
5 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 [] Arthritis [] Asthma [] Blood Disorder [] Cancer [] Depression [] Diabetes [] Epilepsy [] Heart Disease [] High Blood Pressure [] High Cholesterol []Kidney Disease [] Multiple Sclerosis [] Osteoporosis [] Seizures SOCIAL HISTORY Current Marital Status: Living Status: [ ] Married [ ] Single [ ] Divorced [ ] Widowed [ ]Partner [ ] 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 [ ] 1-2 x week [ ] 3 x week 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? Have you tried illicit drugs? [ ] Yes, use now [ ] Never used [ ] Previous user substance? What was the Please check / list all operations: [ ] none [ ] Appendectomy When: [ ] Eye Surgery When: [ ] Tonsillectomy When: [ ] Heart surgery When: [ ] Gall bladder removal When: [ ] Hysterectomy When: [ ] Knee arthroscopy When: [ ] Prostate surgery When: [ ] Knee replacement When: [ ] Surgery for cancer When: [ ] Hip replacement When: [ ] When: [ ] When: [ ] When: Page 5 of 6
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