Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD



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Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine or DenverSpineSurgeons), : Please be sure to fill this out as accurately as possible. This will become part of your permanent medical record and will be used to compare your progress throughout your treatment. Mark the area on your body where you feel the described sensations(s). Use the appropriate symbol(s), mark areas of radiating pain, and include all affected areas. XXXXXXX - - - - - - - Numbness Pain (Sharp/ Stabbing) ******** Pins and Needles 00000000 Ache (Dull) ////////// Burning Weight: lbs Height: ft inches BP: / Pulse: Visual Analog Scale Please mark on the pain level that most accurately represents your pain NO PAIN Today s Pain 0 1 2 3 4 5 6 7 8 9 10 Worst Pain 0 1 2 3 4 5 6 7 8 9 10 Best Pain 0 1 2 3 4 5 6 7 8 9 10 UNBEARABLE PAIN Page 1 of 9

Chief Complaint Reason for todays s visit: History of Present Illness What is your occupation? When did your symptoms start?: Symptoms (specific problems): Is your current problem the result of an accident? (Please circle) No Yes Date of Accident Type (Work, Car, ) Description of Injury Are you currently working? Yes, Full-time Yes, Part-time No N/A Are you on modified duty? Yes No Page 2 of 9

What is the RATIO of neck pain versus arm pain? (ie. 80:20) Neck Pain I have neck pain in the Middle of my neck To the Right To the Left On both sides Neck Symptoms are worse when Neck Symptoms are better when: Do you get headaches? No Yes. If yes, please describe them: Arm / Shoulder Symptoms I have pain in my Right Shoulder/Shoulder Blade Elbow Arm Hand Left Shoulder/Shoulder Blade Elbow Arm Hand I have numbness in my Right Shoulder/Shoulder Blade Elbow Arm Hand Left Shoulder/Shoulder Blade Elbow Arm Hand I have weakness in my Right Shoulder/Shoulder Blade Elbow Arm Hand Left Shoulder/Shoulder Blade Elbow Arm Hand I am Left Handed Right Handed Ambidextrous Arm Symptoms are worse when Arm Symptoms are better when: I have noticed problems with: Gait / Walking / Balance Fine Motor coordination (using buttons, clasps, fine movements) Handwriting is sloppier Clumsiness, dropping things more frequently Bowel or bladder incontinence Page 3 of 9

If you tried any of the treatments below, Please let us know if they are/were helpful? Was it helpful? Physical Therapy Massage Therapy Osteopathic Manipulation Chiropractic Care Bracing TENS Unit Acupuncture Pilates / Yoga Comments Have you had a trial of medications for this problem? No Yes. If yes, please list in the table below Name Strength Formulation Frequency How long? Did it help? Have you had any imaging for this problem? Date CT/Xray/MRI Where were these done? Did you Bring them with you? Have you had pain injections? Date Physician Type of Injection Immediate Relief during the first hour? How long did the relief last? Have you had a recent EMG? No Yes. If yes, who did it and when? Have you ever had spinal surgery before? No Yes. If yes, please list in the table below Date Type of Surgery Surgeon Page 4 of 9

What is the ratio of back pain versus leg pain? (ie. 80:20) Leg Pain I have pain in my Right Buttocks Leg Foot Left Buttocks Leg Foot I have numbness in my Right Buttocks Leg Foot Left Buttocks Leg Foot I have weakness in my Right Buttocks Leg Foot Left Buttocks Leg Foot Leg Symptoms are worse when Leg Symptoms are better when: Back Pain I have back pain in the Middle of my back To the Right To the Left On both sides Back Symptoms are worse when Back Symptoms are better when: I have noticed problems with: Gait / Walking / Balance Bowel or bladder incontinence Page 5 of 9

If you tried any of the treatments below, Please let us know if they are/were helpful? Was it helpful? Physical Therapy Massage Therapy Osteopathic Manipulation Chiropractic Care Bracing TENS Unit Acupuncture Pilates / Yoga Comments Have you had a trial of medications for this problem? No Yes. If yes, please list in the table below Name Strength Formulation Frequency How long? Did it help? Have you had any imaging for this problem? Date CT/Xray/MRI Where were these done? Did you Bring them with you? Have you had pain injections? Date Physician Type of Injection Immediate Relief during the first hour? How long did the relief last? Have you had a recent EMG? No Yes. If yes, who did it and when? Have you ever had spinal surgery before? No Yes. If yes, please list in the table below Date Type of Surgery Surgeon Page 6 of 9

Medications Please fill in the table with medications that you are currently taking Name Strength Formulation Frequency Past Medical History Please list any major or significant illnesses and/or injuries (ie. Diabetes, cancer, heart disease, high blood pressure) Date if applicable 1 2 3 4 5 6 7 8 9 Allergies Please list any allergies to either medications (ie. Penicillin, sulfa) and/or non-medications (ie. shellfish, eggs, latex) Agent Reaction Have you had any problems with anesthesia? No Yes, Page 7 of 9

Please list surgical history Date Surgical History/ Hospitalizations Type of Surgery Please list any hospitalizations for reasons other than surgery or childbirth (ie. Pneumonia, heart failure, infection) Date Reason for hospitalization Family History Please list any significant family illnesses or conditions (ie. Scoliosis, heart disease, diabetes, stroke). If they are healthy, there is no need to fill in that portion of the form. Family Members Status (Healthy/Deceased) Current Age / Age at Death Health Conditions Mother Father Grandmother (Father s) Grandfather (Father s) Grandmother (Mother s) Grandfather (Mother s)) Sister / Brother Sister / Brother Social History Marital Status: Single Married Widowed Do you smoke cigarettes? No Not now, I quit years ago. Yes, I smoke packs of cigarettes a day and have done this for years. Do you use marijuana? No Yes - recreational or medical Do you use tobacco products? Yes, I use Do you drink alcohol? No, never or rarely Yes.. Daily 1 or more times a week 1 or more times a month Do you use street drugs? No Yes Residence House Apartment Assisted Living Page 8 of 9

Review of Systems Please fill in the following form. If you have none of the symptoms listed, please leave the box blank. Fatigue Fever Night Sweats Weight loss General/Constitutional Gastrointestinal Abdominal Pain Blood in Stool Diarrhea Exposure to Hepatitis Hepatitis A Hepatitis B Hepatitis C Heartburn / GERD Rectal Bleeding Decreased hearing Difficulty swallowing Nosebleeds ENT Blood in Urine Painful Urination Genitourinary Endocrine Excessive Sweating Excessive thirst Irregular Menses Diabetes Broken Bones Carpal Tunnel Leg Cramps Painful Joints Musculoskeletal Chest Pain Wheezing Respiratory Peripheral Vascular Decreased Sensation in extremities / peripheral neuropathy Ulceration of feet Swelling in feet Chest Pain Cyanosis Irregular Heart Beat Palpitations Shortness of Breath Cardiovascular Memory Loss Seizures Tremor Previous Brain Injury Concussion Neurologic Page 9 of 9

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