Mid-State Neurosurgery, P.C Back & Neck Pain Center

Transcription

1 Mid-State Neurosurgery, P.C Back & Neck Pain Center Patient Name: Date of Birth: Heart HISTORY Attack OF PRESENT ILLNESS Stroke Seasonal Allergies Diabetes What is the reason for today s visit? When did the problem begin? How did the problem begin? Is your injury due to an accident? Work Accident Car Accident Other Date of Accident: Please describe the details of the accident: Where are your symptoms? Head Right Arm Mid-Back Left Leg Other: Neck Left Arm Low Back Right Leg Do your symptoms travel to any of these locations? Shoulder Forearm Buttocks Calf Foot Upper Arm Fingers Thigh Ankle Toes How often do your symptoms occur? Intermittent Constant How do your symptoms feel? Sharp Pain Dull Pain Numb Weakness Shooting Pain Throbbing Pain Tingling Sensation Other: Stabbing Pain Ache Pins & Needles Do you have any of these symptoms? Bowel Incontinence Difficulty with Balance Coordination Problems Bladder Incontinence Difficulty Walking Headache How much do your symptoms bother you? 0 (No Pain) (Worst Pain Ever) What makes your symptoms better? Lying Down Standing Heat Bending Forward Sitting Walking Cold No Position of Comfortable Other: What makes your symptoms worse? Lying Down Bending Forward Sneezing Movement of Neck Sitting Climbing Stairs Coughing Movement of Arm Standing Sitting to Standing Driving Movement of Leg Walking Lifting Objects Other: 1

2 Heart HISTORY Attack OF PRESENT ILLNESS Stroke Seasonal Allergies Diabetes What tests have been performed? MRI CT EMG/NCV X-rays What treatment have you tried? Oral Steroids Pain Medication Anti-Inflammatory Medicine Muscle Relaxer Physical Therapy Traction Unit Chiropractor Wrist Splints Epidural Steroid Injections Facet Injections Trigger Point Injections Radiofrequency Ablation TENS Unit Other: No Benefit Improved Temporary Relief REVIEW Heart Attack OF SYSTEMS Place a Stroke check next to the symptom below if Seasonal you have Allergies had any of these Diabetes symptoms in the past 3 months. General Respiratory Musculoskeletal Chills Cough Joint Pain Fatigue Shortness of Breath Joint Swelling Fever Wheezing Low Back Pain Weight Gain Muscle Weakness Weight Loss Cardiovascular Neck Pain Chest Pain Integumentary Calf Pain When You Walk Neurological Dry Skin Heart Palpitations Arm Weakness Easy Bruising Leg Swelling Headache Hair Loss Fainting Leg Weakness Hives Loss of Consciousness Rash Gastrointestinal Memory Loss Abdominal Pain Poor Balance Eyes, Ears, Nose, and Throat Bowel Incontinence Seizure Blurry Vision Constipation Double Vision Diarrhea Psychiatric Visual Loss Nausea Anxious Wear Eyeglasses or Contact Lenses Vomiting Depressed Dizziness Insomnia Bloody Nose Genitourinary Trouble Concentrating Hearing Loss Bladder Incontinence Hoarseness Painful Urination Endocrine Sinus Problems Frequent Urination Intolerance to Cold Ringing in Ears Trouble Beginning Urinary Stream Intolerance to Heat Trouble Swallowing Urinary Urgency Excessive Thirst 2

3 Heart MEDICATIONS Attack Please list all medications Stroke and dosages you are currently Seasonal taking, Allergies including over-the-counter Diabetes medications Do you take any of the following medications? Naprosyn Coumadin Vitamin E Aleve Warfarin Glucosamine Naproxen Plavix Advil Aspirin Motrin BC Powder Ibuprofen Goody Powder ALLERGIES Please list any allergies and adverse reactions you have to medications or food Are you allergic to any of the following? Latex Adhesive Tape Gadolinium (MRI Contrast Dye) Iodine (CT Contrast Dye) PHARMACY INFORMATION Please provide the name, street address, and phone number of your pharmacy. Name: Street Address: Phone: PAIN MANAGEMENT Are you currently in Pain Management or receiving pain medicine from another physician? Yes No If yes, please list the name and address of this physician/medical practice: Name: Phone: Address: Fax: 3

4 Heart PAST Attack MEDICAL HISTORY Place Stroke a check next to the disease below Seasonal if you have Allergies ever been diagnosed Diabetes with it in the past. Integuementary Gastrointestinal Endocrine Breast Cancer Crohn's Disease Diabetes Melanoma Cirrhosis High Thyroid Shingles (Herpes Zoster) Diverticulosis Low Thyroid Gallbladder Disease Eyes, Ears, Nose, and Throat Gastric Ulcer Musculoskeletal Cataracts Hepatitis B Compression Fracture Glaucoma Hepatitis C Fibromyalgia Legally Blind Irritable Bowel Syndrome (IBS) Gout Meniere's Disease Liver Cancer Lupus (SLE) Seasonal Allergies Pancreatitis Osteoporosis Ulcerative Colitis Polio Respiratory Psoriatic Arthritis Asthma Genitourinary Rheumatoid Arthritis COPD Bladder Cancer Scoliosis Emphysema Enlarged Prostate (BPH) Lung Cancer Kidney Failure (on dialysis) Psychiatric Pulmonary Embolism (PE) Kidney Stones Anxiety Disorder Sleep Apnea Prostate Cancer Bipolar Disorder Tuberculosis Depression Neurological Cardiovascular Brain Tumor Other Abdominal Aortic Aneurysm Concussion AIDS AICD (Defibrillator) Dementia Endometriosis Atrial Fibrillation Migraine Headache HIV Blood Clot (DVT) Multiple Sclerosis (MS) Leukemia Congestive Heart Failure Parkinson s Disease Lyme Disease Heart Attack Seizure Disorder Substance Abuse High Blood Pressure High Cholesterol Pacemaker Peripheral Vascular Disease (PVD) Stroke PAST SURGICAL HISTORY List any back, neck, or brain surgery you have had with the approximate year. Place a check next to any other surgeries/procedures you have had. Neck Surgery: Carpal Tunnel Gallbladder Removed Ulnar Nerve Gastric Bypass Spinal Cord Stimulator Heart Valve Replacement Intrathecal Pain Pump Hernia Repair Hip Replacement Back Surgery: Abdominal Aortic Aneurysm Hysterectomy Appendectomy Knee Replacement Ankle Surgery Mastectomy Bladder Stimulator Pacemaker Cardiac Bypass Prostate Surgery Brain Surgery: Cardiac Stent Shoulder Surgery Carotid Artery Plaque Removal Thyroid Removed Carotid Artery Stent Tonsillectomy Cataract Other: Colonoscopy Have you ever had a problem with anesthesia? Yes No If yes, please explain: Have you ever had a blood transfusion? Yes No If yes, why? 4

5 SOCIAL HISTORY Job Title: Employer Name: Current Work Status: Do you drink alcohol? Do you smoke? Full Time Yes, Every day Yes, Every day Part Time Yes, Some days Yes, Some days Unemployed Yes, Only Socially No, I quit Self Employed No, I quit No, I have never smoked Retired No, I have never drank alcohol Disabled Marital Status: Married Single Divorced Widowed Domestic Partner Do you have children? Yes No If yes, how many sons? If yes, how many daughters? FAMILY HISTORY Please check if your mother, father, or siblings has or had any of the following diseases. Patient is adopted Asthma Anxiety Disorder Bipolar Disorder Brain Tumor Breast Cancer Congestive Heart Failure Depression Diabetes Fibromyalgia Heart Attack Hepatitis C High Blood Pressure High Cholesterol High Thyroid Low Thyroid Lung Cancer Lupus (SLE) Osteoporosis Prostate Cancer Rheumatoid Arthritis Scoliosis Stroke Tuberculosis Other Cancer Mother Father Sister(s) Brother(s) 5