Full name DOB Age Address Phone numbers (H) (W) (C) Emergency contact Phone

Transcription

1 DEMOGRAPHIC INFORMATION Full name DOB Age Address Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address Phone Fax REASON FOR VISIT Please describe the major problem that brings you in today to see a spine surgeon: Is this visit related to worker s compensation? No Yes Is this visit related to any legal actions? No Yes If this problem is the result of an accident, when did the accident occur? Was it a motor vehicle accident? No Yes Page 1 of 5

2 MEDICAL HISTORY Height feet inches Weight pounds Please list all OPERATIONS you have had. Please list all ACTIVE MEDICAL PROBLEMS. Date: Duration: Please list all MEDICATIONS you take routinely, prescribed or over-the-counter, along with the dosages: Medication: Dose: Frequency: Are you ALLERGIC to any medicines, latex, x-ray dye, or iodine? If yes, please explain: Have you had any PROBLEMS WITH ANESTHESIA? If yes, please explain: Are you taking any BLOOD THINNING MEDICATIONS? Yes indicate below Aspirin or aspirin-containing medication Anti-inflammatory medication (for example, Advil, Motrin, Celebrex) Plavix Coumadin Fish oil Other: Page 2 of 5 No

3 REVIEW OF SYSTEMS CARDIOVASCULAR Chest pain/pressure Fainting Heart attack Heart defect Heart murmur High blood pressure Low blood pressure Leg swelling CONSTITUTIONAL Altered taste/smell Change in appetite Excessive sleepiness Fatigue Fever Depression Anxiety Recent sore throat Sleep apnea Weight loss or gain EAR, NOSE, & THROAT Hearing loss Mouth sores Ringing in ears Sinus disease Trouble swallowing EYES Blurred vision Cataracts Double vision Glaucoma Macular degeneration Peripheral vision issue Visual impairment GASTROINTESTINAL Black stool Constipation Diarrhea Gall bladder problems Ulcer Vomiting SKIN Birth marks Psoriasis Skin rashes Melanoma RESPIRATORY Asthma Bronchitis Chronic cough COPD Emphysema Pneumonia Shortness of breath Trouble breathing Tuberculosis Wheezing MUSCULOSKELETAL Connective tissue disorder Low back pain Neck pain Joint pain Joint replacement Joint swelling GENITOURINARY Blood in urine Change in habits Urinary infections Kidney disease Kidney stones Loss of control Painful urination Urinary urgency Vaginal bleeding HEMOLYMPHATIC/ ENDOCRINE Anemia Blood disorder Circulatory problems Diabetes Dry eyes/mouth Endocrine disorder Low blood sugar Lymph node swelling Hepatitis HIV/AIDS Pituitary disorder Sickle cell disease Thyroid disease NEUROLOGICAL Balance difficulty Choking Clumsiness Concussion Confusion Concentration difficulty Dizziness Drooling Falls Hallucinations Headache Loss of consciousness Memory problems Muscle twitching Nausea Numbness Personality change Seizure Shooting pains Smelling difficulty Stroke Tasting difficulty Tingling sensation Vertigo Walking difficulty Page 3 of 5

4 SOCIAL HISTORY Are you married? No Yes Separated/divorced Widow(er) What is your SMOKING HISTORY? Currently smoke every day How much daily? Currently smoke some days How much weekly? Formerly smoked Never smoked Do you drink alcohol? No Yes Drinks per day: Use any recreational drugs? No Yes Please specify: Prior alcohol or drug abuse? No Yes Please explain: Do you participate in activities inside the home (i.e. vacuuming, cooking, general housework)? No Yes If yes, describe your level of activity: Sendentary or light Moderate Strenuous Do you participate in activities outside the home (i.e. gardening, golf, walking, cycling, volunteering)? No Yes If yes, describe your level of activity: Sendentary or light Moderate Strenuous What is the highest level of EDUCATION you have achieved? (Check one) Less than high school High school diploma or GED Two-year college degree Four-year college degree Post-college Are you currently EMPLOYED (paid employee or self-employed)? (Check all that apply) Employed and currently working Unemployed Full time On disability Part time Retired Employed but not working Homemaker On short-term disability None of the above On leave Attending school If disabled or unemployed, is this due to your spinal condition? No Yes Was your spinal condition work related? Yes No Unknown Which description best characterizes your occupation? Sendentary: requires the ability to sit up to 6 hours in an 8-hour work day, lift light objects such as files and paperwork frequently during the day, and objects weighing up to 10 pounds occasionally during the day Light: requires the ability to stand up to 6 hours in an 8-hour work day, lift up to 10 pounds frequently and up to 20 pounds occasionally Medium: requires the ability to stand up to 6 hours in an 8-hour work day, lift up to 25 pounds frequently and 50 pounds occasionally Heavy: requires the ability to stand up to 6 hours in an 8-hour work day, lift up to 50 pounds frequently and lift more than 50 pounds occasionally Page 4 of 5

5 FAMILY HISTORY If you have any relatives, including children, with serious medical conditions (such as asthma, high blood pressure, heart attacks, kidney problems, diabetes, seizures, strokes, cancer, etc.) please list below. Relationship Age Condition Relationship Age Condition Relationship Age Condition Relationship Age Condition Relationship Age Condition Relationship Age Condition Do you have children? No Yes If yes, age(s) and condition SIGNATURES This form is confidential and is part of your medical record. Completed by: Printed Signature Date Reviewed by:, M.D. Printed Signature Date Page 5 of 5