Medical College of Wisconsin, Department of Orthopaedic Surgery

Edward P. Southern, M.D. Page 1 SPINE CENTER PATIENT QUESTIONNAIRE All questions must be answered accurately to help us evaluate and treat your problem. Ask the nurse for any question(s).

DATE NAME ___ AGE SEX: M F

Who referred you to this clinic? (name and address)

Name of your primary care physician (name and address)

Onset of symptoms: Date of onset: Gradual Sudden How long: Accident : Yes No Date: Car Accident Lifting Bending Twisting Falling Hit by an object Other Place of Injury: At work Other

QUALITY AND LOCATION OF YOUR SPINE PAIN Area of involvement : Back pain Neck pain Both (for arm or leg pain see below) Severity of pain: (On a scale of 1 to 10, 10 being worst possible) Rated at its worse, what # At its best what # Nature: Sharp Dull Ache Burning Numbness Pins & Needles What affects your pain? Posture: Worse with: Standing Walking Sitting Lying No difference Better with: Standing Walking Sitting Lying No difference Worse with coughing? Worse with bowel movement? Time-Dependent Pattern Progress: Improving Same Getting Worse Worse in: Morning Afternoon Night Other characteristics about your spine pain:

QUALITY AND LOCATION OF YOUR EXTREMITY PAIN Leg pain: Right Left Both Right and left Arm pain: Right Left Both Right and Left Severity of pain: (On scale of 1 to 10, 10 being worst possible) Rated at its worst, what # At its best what # Nature: Sharp Dull Ache Burning Numbness Pins & Needles Radiation: Leg: to hip or thighs to below knees to toes Arm: to shoulder to elbow to fingers What affects your pain? Posture: Worse with: Standing Walking Sitting Lying No difference Better with: Standing Walking Sitting Lying No difference Worse with Coughing Worse with bowel movement Time-Dependent Pattern: Improving Same Getting Worse Worse in: Morning Afternoon Night Other characteristics about your arm/leg pain:

MOTOR FUNCTION Weakness in: Arms Legs Both Where? Do you have trouble with balance, equilibrium or night walking? Yes No Problems with: Bowel: Yes No Bladder: Yes No

PAST HISTORY: Previous back/neck pain or problems: Yes No If yes, describe:

Previous Therapy/Treatment (including non-medical or “alternative medicine” i.e. acupuncture, chiropractic, herbal medicine)

transcutaneous electrical nerve stimulation (TENS) Yes No

Previous back/neck surgery: Yes No If yes, date and type of surgery:

Spine Patient Questionnaire Page 2 Past medical problems: (Please list all previous medical problems; they may be important for your treatment)

Past surgical problems: (Please list all previous surgeries; they may be important for your treatment)

ALLERGIES: Yes No Describe:

MEDICATION: Narcotics Yes No Aspirin or aspirin-like drugs (NSAID’s) Yes No Acetaminophen Yes No List all current medications:

FAMILY HISTORY: Any history of spine problems in the family? Yes No If yes, specify:

Are there any other medical problems in family members? Please list who and what is wrong:

SOCIAL HISTORY Is there any involvement with: Disability Litigation Workers Compensation Job/work (occupation and physical requirements)

Are you currently working? Yes No off due to: injury I am retired I am a student I am not working by choice No, I am off work for other reasons: ______

Married Single Divorced/Separated Widowed

Smoking: Yes No Quit smoking If quit, when did you quit? Cigarettes Cigars Pipes Oral (chew/snuff) How long did/have you smoked (years)? How many packs/day? Alcohol use: Heavy Moderate Occasional None

CONSTITUTIONAL SIGNS / REVIEW OF SYSTEMS: fever eye problems cough night sweats ear problems breathing difficulty cold sweats nose problems bleeding problems weight loss throat problems stomach pain weight gain chest pain urinary dysfunction vision problems palpitations bowel dysfunction

“Is there anything else bothering you?”

PAIN DRAWING Draw on the diagram showing where your pain is and how it feels. Use the key below to indicate type of pain. Use the correct symbol on the picture to show where your pain is located.

Show both your leg and back pain; be as accurate as possible in its location.

Speak to the staff for assistance, if needed. Spine Patient Questionnaire Page 3