COMPREHENSIVE SPINE CENTER
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- Charla Harrison
- 7 years ago
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1 Dear Esteemed Patient: CSC Physicians: Ulrich Batzdorf, MD; David E. Fish, MD; Langston Holly, MD; Jae Jung, MD; Duncan Q. McBride, MD; Don Y. Park, MD; Nick Shamie, MD; Daniel Lu, MD, PhD COMPREHENSIVE SPINE CENTER 1131 Wilshire Blvd, Suite 100 Santa Monica, CA DISK (Appointment) (Fax) Thank you for choosing to make an appointment at the UCLA Spine Center located at 1131 Wilshire Blvd, Suite 100 in Santa Monica. Please be sure to bring the following to your appointment: o Your most current diagnostic films and reports (e.g. MRI, CT, plain x-rays; SSEP or EMG reports; Physical Therapy reports; Pain Medicine reports, etc.) pertaining to your current medical condition. (PLEASE NOTE: If your films were done within the UCLA system at Santa Monica or Westwood, our office will make sure that they are here for your visit and you do not need to pick up these films. However, if you had films done outside of UCLA, you do need to bring these with you). o o o o Prior medical records and consultations from your referring physician and any other specialist you've seen for your current condition. To help expedite your visit, please hand carry your reports to this office. Do not send them prior to your appointment. Your medical insurance card (s) If you have HMO Insurance: Please be sure to bring your "Letter of Authorization: from your HMO. If you do not bring your authorization letter and we do not have written authorization on file, you will be financially responsible and will be asked to pay the consultation fee on the day of your appointment. If you have HMO Insurance: Please be sure to bring your co-payment with you. We accept cash, check, or Visa/Mastercard. Attached you will find a questionnaire and a map with directions to our location. Please bring in the completed paperwork to your appointment. If you have any questions, please feel free to contact the UCLA Spine Center Appointment Scheduling desk at (310) We look forward to seeing you. PLEASE NOTIFY US OF ANY CANCELLATIONS AT LEAST 24 HOURS PRIOR TO YOURAPPOINTMENT On your initial visit you will be seen by the Orthopaedic Spine Specialist, Don Y. Park, MD, who will, with or without a Spine Fellow and /or Resident and /or Physician's Assistant and /or Nurse Practitioner student, obtain a medical history and perform a physical examination. The SM/UCLA Comprehensive Spine Center advocates a multi-disciplinary approach to strive and attain the best possible healing and recovery for every patient. Because every patient is unique, we prescribe treatment based on a thorough evaluation, that we perform utilizing the latest technological advancements available. We believe in evaluating patients promptly and educating them on their diagnosis, so they can play an active role in the decision-making and treatment process. Our physicians' clinical experience has shown that patients who participate in their own health care decisions are far more likely to achieve an optimal level of healing and recovery. Sincerely, Patient Care Coordinator SM/UCLA Comprehensive Spine Center
2 Date: Please take the time to answer a few questions regarding your symptoms. Pain Diagram Please draw out your symptoms on the diagram below using the following symbols: Numbness: Pins & Needles: Stabbing: ////// Burning: xxxxx History: Age: Gender: Chief complaint: What is your dominant hand? Right Left Date of injury? What is your current pain level? [ ] (Please circle; 0: no pain, 10: worst pain imaginable) When did your symptoms first start? When did your symptoms get worse? What is worse: your neck back pain your arm leg pain? Is your pain: Constant Intermittent Occasional? Is your pain: Getting better Getting worse Staying the same? Page 2 of 6
3 Is your pain worse: When first getting up from bed? At the end of the day? When changing positions? What makes your pain worse? (sitting, standing, walking, bending forward, leaning back, twisting, etc) What makes your pain better? (sitting, standing walking, lying down, bending forward, leaning back, etc) Are you having any of the following difficulties? (Please check if applicable) Loss of bladder control Urgent desire to urinate Loss of bowel control Loss of sensation in genitalia and anal region Difficulty walking Limping Use of cane, crutch, or walker Use of wheelchair Problems with balance I have none of these Do you have any weakness? Arms Hand Legs Feet Do you have numbness or tingling? Where? Do you have headaches associated with your symptoms? Are you having any difficulty handling small objects? (pins, coins, needles, buttons, etc) Have you had a steroid injection in the past? When? Did the injection help? Have you had physical therapy in the past? When? Did physical therapy help? Any previous treatments for your symptoms? (Chiropractor, acupuncture, injections, previous surgery) Any improvement? What pain medicines are you using now? Any relief? Page 3 of 6
4 Please take the time to complete this form to better understand your history. Past Medical History (Please check YES or NO for any significant conditions) Anemia Heart Defect Asthma Heart Attack Arthritis Heart Failure Alcohol dependency High Blood Pressure Arrhythmia High Cholesterol Anxiety Immune Disorder Bleeding/Bruising Intestinal Problems Blood Disorder Kidney Disease COPD Liver Disease Chronic Bronchitis Migraine/Headache Cancer Osteoporosis Depression Obesity Diabetes Stroke Drug Abuse Sinus problems Epilepsy/Seizures Thyroid Disease Emphysema Tuberculosis (TB) Hay Fever Stomach Ulcers Other (Please list): - Past Surgical History (Please list all surgeries and approximate dates) Medications (Please list name, dose, and frequency of all medications) Allergies (Please list all medication and latex allergies and describe reaction) Page 4 of 6
5 Social History Do you smoke cigarettes? Packs per day? How many years? If you quit, when? Do you use any other forms of tobacco? What type? Do you drink alcohol? How often and how much? Do you use drugs other than prescribed or over the counter medications? What do you use? Birthplace? Marital Status/Relationship? Current Occupation: Family History (Please list medical problems in your family) Age Medical Problems If decreased, cause of death Father Mother Siblings Children Grand- Parent Page 5 of 6
6 Review Review of Systems: (Please check if applicable) None are applicable General Good health Recent w eight changes Fatigue Recurrent fever or chills Headache Skin/Breast Rashes Lumps Itching Color changes Hair and nail changes Pain Discharge Ear/Nose/Throat Decreased hearing Ringing in ears Pain Drainage Stuffiness Discharge Nosebleeds Sinus pain Dry mouth Sore throat Hoarseness Non-healing sores Bleeding Swollen glands Eyes Glasses or contacts Pain Redness Blurry or double vision Glaucoma Cataracts Respiratory Cough Sputum Coughing up blood Shortness of breath W heezing Painful breathing Cardiovascular Chest pain or discomfort Tightness Palpitations Shortness of breath with activity Difficulty breathing lying down Swelling Sudden awakening from sleep with shortness of breath Gastrointestinal Swallowing difficulties Heartburn Change in appetite Nausea Change in bowel habits Rectal bleeding Constipation Diarrhea Yellow eyes or skin Genitourinary Frequency Urgency Burning or pain Blood in urine Incontinence Change in urinary strength Male- Pain with sex Hernia Penile discharge Sores Masses or pain Erectiledysfunction ST D s Female- Pain with sex Vaginal dryness Hot flashes Vaginal discharge Itching or rash ST D s Vascular Calf pain with walking Leg cram ping Varicose veins Musculoskeletal Muscle or joint pain Stiffness Back pain Redness of joints Swelling of joints Trauma Neurologic Dizziness Fainting Seizures W eakness Numbness Tingling Tremor Hematologic Ease of bruising Ease of bleeding Endocrine Heat or cold intolerance Sw eating Frequenturination Excess thirst Change in appetite Psychiatric Nervousness Depression Memory loss Stre s : Name of person completing form Signature: Relationship (if other than patient): Page 6 of 6
7 Health Questionnaire English version for the US US (English) 1998 EuroQol Group. EQ-5D is a trade mark of the EuroQol Group
8 By placing a checkmark in one box in each group below, please indicate which statements best describe your own health state today. Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed 2 US (English) 1998 EuroQol Group. EQ-5D is a trade mark of the EuroQol Group
9 To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today. Best imaginable health state Your own health state today US (English) 1998 EuroQol Group. EQ-5D is a trade mark of the EuroQol Group Worst imaginable health state
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