Alaska Spine Institute

Electrodiagnostic Testing

NAME:______DATE:______

DATE OF BIRTH: ______AGE: ______SEX: M F

REFERRING PHYSICIAN: ______

WHEN DID YOUR SYMPTOMS BEGIN? ______

IS THIS WORK RELATED? ______

DESCRIBE YOURCOMPLAINTS:______

______

SYMPTOMS ARE WORSENED WITH: ______

______

SYMPTOMS ARE IMPROVED WITH: Rest/Bed Lying down Walking/Standing Time of day

Being around people Sexual activity Physical activity Drugs Exercise Other ______

RECENT PRIOR TESTING: TEST WHEN WHERE XRAYS CT SCAN/ MRI EMG/NCV OTHER

PAST MEDICAL HISTORY:

 Diabetes  High blood pressure  Hepatitis  Thyroid Disease  Ulcer  Cancer If so what kind?______ Heart Disease  Tuberculosis  Lung Disease  Kidney  Arthritis  Depression  Other Illnesses Disease

Prior Hospitalization:______

Surgical History ( Procedure and Year):______

______

TURN PAGE OVER AND COMPLETE OTHER SIDE Patient Name:______Date of Birth:______FAMILY HISTORY:

 Diabetes  High blood pressure  Cancer If so what kind ______ Hear Disease t  Depression  Disability  Chronic pain  Stroke  Alcoholism  Migraine  Other

SOCIAL HISTORY: Occupation______Currently Working? YES NO

Smoke: YES NO How much? ______How Long? ______

Alcohol: YES NO How much?______How Long?______

Marital Status  Married  Single  Divorced  Separate  Widowed How long? d

MEDICATIONS:______

______

ALLERGIES: ______

YOU MAY USE THE AREA BELOW FOR ANY ADDITIONAL COMMENTS OR INFORMATION THAT YOU FEEL IS IMPORTANT REGARDING YOUR CURRENT MEDICAL CONDITION.

Patient Name:______Date of Birth:______

What is your average pain? Or give a range of your level of pain. “0” indicates NO PAIN and “10” indicates pain so severe it would cause you to faint or lose consciousness

Patient Name:______Date of Birth:______0 1 2 3 4 5 6 7 8 9 10 |_____|_____|_____|_____|_____|_____|_____|_____|_____|_____|

Please review the following list of medical problems and mark any that apply to you now or in the past. Please go over the list carefully. Medical problems that do not seem related to your current situation could result in a serious complication if you do not let us know about them. Constitutional Respiratory Neurologic Recent weight gain: ____ lbs Asthma or wheezing Seizures or convulsions Recent weight loss: ____ lbs Bronchitis Epilepsy Fever or soaking sweats at night Emphysema Stroke Fatigue Pneumonia Brain aneurysm or hemorrhage Weakness/numbness of arms/legs Chronic cough Multiple Sclerosis Headaches ≥1-2 times per week Change in amount of phlegm Nerve Injury or Numbness Difficulty walking Change in color of phlegm Psychiatric Loss of consciousness/convulsions Coughing up blood Depression Eyes Collapsed lung Anxiety or panic attacks Vision problems not corrected by glasses Tuberculosis exposure Mental disorder Glaucoma Blueness of your fingernails Endocrine Eye lens implant Gastrointestinal Diabetes Eye prosthesis Ulcers Insulin use Contact lenses Hiatal hernia or frequent heartburn Low blood sugar or hypoglycemia Ears, Nose, Throat Ulcerative colitis Thyroid problems Chronic stuffy nose or nasal polyps Diverticulitis Steroid use Frequent nosebleeds Colostomy or other ‘ostomy’ Allergic/Immunologic Sinus problems Hepatitis or yellow jaundice Herpes exposure Hay fever allergies Liver cirrhosis AIDS exposure Difficulty hearing Gallbladder problems Street drug use Ear infections Vomiting blood Hematologic Hearing aid Black, tarry bowel movements Abnormal bleeding problems Chronic sore throat or tonsillitis Blood in bowel movements Anemia or low blood count Hoarseness Change in bowel habits Blood transfusion Difficulty swallowing Genitourinary Hemophilia Dentures or partial plates Kidney stones Sickle cell anemia Capped teeth Kidney infections Lymphatic Loose teeth Kidney failure Swollen glands or masses in neck, Orthodontic braces Dialysis axillae, groin Cardiovascular Prostate problems Lymphedema Heart murmur Bladder infections Others Prolapsed mitral valve Blood in urine Sexual problems Heart pacemaker Difficulty urinating Muscular dystrophy Irregular heartbeat Do you lose your urine at times Myasthenia gravis Palpitations or rapid pulse Musculoskeletal Malignant hyperthermia Fainting spells Fractures or broken bones Bad reaction to local anesthetic Chest pain or angina on exertion Arthritis Down syndrome Chest pain or angina at night Difficulty opening mouth wide Cancer or tumor Heart attack Scoliosis Chemotherapy Congestive heart failure Spinal column deformity Radiation therapy

Patient Name:______Date of Birth:______Swelling in feet or ankles Integumentary/Dermatologic Recent acute illness Shortness of breath lying flat Skin rash or sores Recent hospitalization Shortness of breath at night Itching Recent surgical operation Blood clots or pulmonary embolism Color change, pigmentation, nodules High blood pressure Pressure ulcers Use the back of this page to list Low blood pressure any problems not already covered that you consider important ______For women only: Are you pregnant? Yes No Number of pregnancies: ______Are menstrual periods normal? Yes No Number of deliveries: ______Any vaginal discharge Date of last menstrual period: ______Bleeding between periods Approx date of last pap smear: ______Bleeding after menopause ______I have carefully reviewed this checklist and completed it to the best of my knowledge. Date: ______

______Signature of Patient, Parent, or Guardian Relationship to patient, (if not self)

Patient Name:______Date of Birth:______