Illinois Sw Orthopedics, Ltd

ILLINOIS SW ORTHOPEDICS, LTD.

PATIENT PAIN DREAWING

Name: ______Date: ______

Where is your pain now?

Mark the areas on your body where you feel sensations described below, using the appropriate symbol. Mark the areas of radiation, include all affected areas. To complete the picture, please draw in your face.

Aching Numbness Pins/Needles Burning Stabbing ▲ = = = = =  xxxxxx / / / / / / /

R L L R

FRONT BACK

How bad is your pain now?

Please mark with an X on the body form where the pain is worst now.

Please mark on the line how bad your pain is now.

No Pain ______Worst Possible Pain

Age:______

Height:______

Weight:______

Occupation: ______

Date of Accident: ______Is injury work related: (if yes, please give details of the accident)

Out of work: Days: ______Months: ______Years: ______

List in order your primary complaints: 1. 2. 3.

Briefly describe your back/neck pain:

How long have you had your present attack of back/neck pain? Days: ______Months: ______Years: ______

How long have you had your present attack of leg/arm pain? Days: ______Months: ______Years: ______

When were you first aware there was something wring with your back/neck? Days: ______Months: ______Years: ______

How many attacks of back/neck pain have you had per year? ______

On a scale of 1-10,with 0 being now pain and 10 being pain so severe that you could not live with it for more than a few minutes, how would you rate your pain now? Back______Right Leg______Left Leg______Neck______Right Arm______Left Arm ______

Did your back/neck pain get better once the leg/arm pain started?

Is your back/neck pain Constant______Intermittent______

Is your pain worse on first arising in the morning?______

Do you have weakness in your legs or arm?______

Have you ever been told you have cancer? (if yes, please give details)

Have you had any problems with any of the following symptoms recently? (Please circle)

 Feel like you must urinate and cannot  Increase pain with activity (walking, standing, etc)  Dribbling  Increase pain with bending  Loss of Feeling to void  Increase pain with coughing/sneezing  Inability to void  Fevers/Chills  Urgent desire to void and cannot hold it  Difficulty with sex  Constipation  Increase pain with pushing an object (e.g. vacuum cleaner) Which of the following treatments have you had and what affect did it have on your pain? Better Same Worse Bed rest Walking Traction Chiropractor Have you had any surgery on your back or Physical Therapy neck? (if yes, give details) Massage Injections Heat Acupuncture TENS Have you had any of the following tests? Medication When Where BraceX-Rays CT Myelogram MRI Bone Scan EMG

Social History: Single______Married ______Divorced ______Widowed______Do you live alone? ______(if no, with whom do you live?) Do you smoke? ______Number of packs per day______How many years______Average ounces of liquor per day? ______(1 beer = 1 ounce or 1 glass of wine = 1 ounce)