First Visit Patient Form

AOK SPINE AND PAIN FIRST VISIT PATIENT FORM

Please circle answers to questions that pertain to your problem. You may select more than one answer per question. This information will help get an accurate appraisal of you problems, develop an appropriate plan of treatment, and will be included in your visit note. If you have questions, please ask for assistance.

Referred by: ______Is this a second opinion? ______

NAME ______DATE ______AGE ______

ARE YOU: (A) Right handed (B) Left handed (C) Ambidextrous

SEX: (A) Male (B) Female OCCUPATION: ______

COMPLAINT (What are you being seen for?) A. Neck pain Do you have any: B. Neck pain with headaches A. Weakness C. Upper back pain B. Numbness D. Lower back pain C. Tingling E. Right leg pain D. If so, where? ______F. Left leg pain ______. G. Pain in both legs H. Right arm pain I. Left arm pain J. Scoliosis K. Other: ______

If one or more of the above is chosen, which is the most problematic? ______?

Which term best describes your neck/back pain? Which term best describes your arm/leg pain? A. Sharp A. Sharp B. Stabbing B. Stabbing C. Burning C. Burning D. Like electricity D. Like electricity E. Dull ache E. Dull ache F. Pins and needles F. Pins and needles

When did the problem start? ______?

If problem was caused from an injury, what is the date of injury? ______Was the injury job related? (A) Yes (B) No How did the injury occur? A. No injury G. Job related B. Motor vehicle accident-no litigation H. Other ______C. Motor vehicle accident-litigation pending D. Motor vehicle accident-litigation complete E. Fall F. Sports or recreation If motor vehicle accident, were you: A. Driver B. Front seat passenger C. Rear seat passenger D. Motorcycle driver E. Motorcycle passenger F. Other ______

Were you wearing a seatbelt? (A) Yes (B) No

Have you incurred any other injuries due to this condition? (A) No (B) Yes, explain: ______

______.

Please briefly explain the circumstances that led to your condition: ______

______

What treatments have you already received for this condition? A. Medication(s) list: ______B. Physical therapy (how many weeks?) ______C. Chiropractic care (how many weeks?) ______D. Epidural injections- How many injections? ______When was the last? ______E. Other- please list: ______

Since the pain/condition began it: What time of the day is the pain most intense? A. Has improved A. On first arising in the morning B. Has worsened B. During the daytime or while at work C. Has stayed the same C. At the end of the day before bedtime D. Fluctuates D. During the night

What aggravates the pain? What makes the pain better? A. Walking A. Sitting B. Standing B. Lying down C. Sitting C. Walking D. Lying down D. Standing E. Activity in general E. Nothing in particular F. Stooping/bending F. Other/-list: ______G. Nothing in particular H. Other- list: ______

Does the pain awaken you from sleep? Does the pain keep you from sleeping? A. Never A. Never B. Occasionally B. Occasionally C. Frequently C. Frequently

Do you have difficulty walking? Is walking difficulty related to this condition? A. No A. Yes B. Yes, can walk unlimited distances B. No, explain: ______C. Yes, can walk less than a mile D. Yes, can walk only 1-2 blocks ______E. Yes, can walk less than 1 block F. Yes, non-ambulatory (cannot walk) ______. G. Other ______

Have you had any problems with bowel, bladder, or sexual functions since this condition began? A. No B. Yes, please explain: ______

______.

Have you had a previous back or neck problem? A. No B. Yes, please explain: ______

______.

Do you exercise regularly? A. No B. Yes. How often? ______

PAST MEDICAL/SURGICAL HISTORY

Do you have a history of any of these medical conditions?

Diabetes YES NO Liver disease YES NO ____ Diet controlled ____ Medication controlled Kidney disease YES NO ____ Insulin controlled Hepatitis YES NO Type? ______High blood pressure YES NO Immune disorder YES NO Heart disease YES NO ____ Chest pain/angina Seizure(s) YES NO ____ Heart attack, Date ______Valve disease Eye problems YES NO

Cancer/Tumor YES NO Headaches YES NO What type? ______Thyroid disorder YES NO Ulcers YES NO Osteoarthritis YES NO

Lung disease including YES NO Rheumatoid arthritis YES NO Emphysema Asthma YES NO Stroke YES NO When? ______Mental disorder YES NO Explain: ______Circulation problems YES NO Other ______High cholesterol YES NO ______.

Have you ever had any neck or back (spine) operations? A. No B. Yes. How many? ______

Please list your previous operations below

Date Place Surgeon Procedure

______

Have you had any other surgical procedures that are not spine related? A. No B. Yes

Please list below

Date Procedure

______

CURRENT MEDICATIONS A. None B. I am currently taking medication

Please list below

Name Dose What is the medication for?

______

ALLERGIES

Do you have any allergies? A. No known allergies including iodine/contrast dye or shellfish B. Yes, please list: ______

______.

SOCIAL AND FAMILY HISTORY

Marital status: (A) Single (B) Married (C) Divorced (D) Widowed How many children do you have? ______What is the highest level of education you have completed?

(A) Some high school (B) High school (C) Trade school (D) College (E) Professional school

Do you smoke? (A) No (B) Yes; packs per day? ______How many years have you been smoking? ______

Do you smoke a pipe? (A) No (B) Yes How often? ______Do you smoke cigars? (A) No (B) Yes How often? ______Do you use smokeless tobacco? (A) No (B) Yes How much? ______Did you ever smoke regularly before? (A) No (B) Yes; packs per day? ______How many years did you smoke? ______When did you quit smoking? ______

How much alcohol do you consume in an average week? (beer, wine, etc.) A. None B. Less than 6 drinks C. 6-12 drinks D. 12-24 drinks E. 24-48 drinks F. More than 48 drinks

What is your current work status? A. Regular employment-no restrictions B. Full time with restrictions C. Part time by choice D. Part time with restrictions E. Part time due to a spine condition F. Part time due to other medical condition. Specify: ______G. Retired by choice H. Retired due to spine condition I. Retired due to other medical condition. Specify: ______J. Unemployed—looking for work with no restrictions K. Unemployed—looking for light duty work L. Unemployed M. Currently not working due to spine condition N. Currently not working due to other medical condition O. Student

Do you have a family history of any of these conditions or diseases? (Circle all that apply) A. Back or neck problems B. Cancer C. Diabetes D. Heart disease E. Hypertension F. Osteoarthritis (wear and tear) G. Rheumatoid arthritis H. Scoliosis I. Stroke J. Other ______

REVIEW OF SYSTEMS

Have you recently experienced any of the following? Circle all that apply

General: Heart:

Weight gain Chest pain Weight loss Palpitations Fever Fainting Chills Night sweats

Skin: GU: Change in moles Frequent urination Breast lumps Difficulty with urination Blood in urine

Eyes: Vascular:

Loss of vision Swelling in lower extremities Double vision Emboli (blood clots)

ENT: Musculoskeletal:

Hearing loss Muscle weakness Nose bleeds Stiffness Joint pain

GI: Psych:

Nausea Anxiety Vomiting Depression Change in bowel habits Confusion Heartburn Memory loss

Respiratory:

Shortness of breath Coughing/wheezing

Dr. Signature ______Please fill in the pain drawing. This will help us understand what your pain is like and where it is now. Using the appropriate symbol, fill in the affected areas.

Numbness, tingling, pins/needles: ooooooooo Pain, aching: xxxxxxxxxxxx