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David W. Wimberley, MD

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David W. Wimberley, MD David W. Wimberley, MD Please fill out these forms completely! Patient Name:_________________________ We know that filling out these forms can be difficult, but please complete them carefully. Your accurate responses will give us a better Date: ________________________________ understanding of you and your problems. From this information we can provide you Gender: Male Female Handedness: R L the best care possible. Please be careful to follow the directions in each section. Clearly mark Date of Birth: _________ Current Age: ______ the check boxes, and fill in the blanks where indicated. Thank you for helping us get to know you better! Height:__________ Weight:__________ How bad is your pain? Circle the number on each of the lines below Please identify which ONE of the following best describes your spine to indicate your pain. (back or neck) vs extremity (arm or leg) pain: 100% Spine pain to 0% Extremity pain How bad is your neck pain? 90% Spine pain to 10% Extremity pain No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst possible 80% Spine pain to 20% Extremity pain How bad is your arm pain? 70% Spine pain to 30% Extremity pain No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst possible 60% Spine pain to 40% Extremity pain How bad is your middle back pain? 50% Spine pain to 50% Extremity pain No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst possible 40% Spine pain to 60% Extremity pain How bad is your low back pain? 30% Spine pain to 70% Extremity pain No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst possible 20% Spine pain to 80% Extremity pain How bad is your leg pain? 10% Spine pain to 90% Extremity pain No Pain 0 1 2 3 4 5 6 7 8 9 10 Worst possible 0% Spine pain to 100% Extremity pain Patient Initials___________ Date__________ Page 1 David W. Wimberley, MD FACTORS OF COMPLAINT What would you like to happen as a result of How / when did your problem begin? (please mark all that apply this visit? to your neck / back pain) I don’t know how it began ____________________________________ It comes and goes I’ve had it a long time (______ years) Injury (date of injury_______ ) on the job? yes no ____________________________________ Please explain how injury happened __________________________________________ ____________________________________ Are you currently in litigation with regards to your back pain? yes no ____________________________________ Have you been laid off from your job? yes no N/A ______ Is your pain worse at night? yes no Bladder Control (urine): Does your pain awaken you from sleep? yes no No problem Does coughing affect your pain? yes no Can’t empty bladder Loss of urine (accidents) Do your legs tire / hurt if you walk too far? yes no If YES, how far can you walk? Bowel Control: less than 1 block 1-3 blocks more than 3 blocks No problem Is this relieved by resting your legs? yes no Constipation Is this relieved by bending forward? yes no Loss of control (accidents) How does each of the following affect your pain? (check all that apply) Sitting Better Worse No change Standing Better Worse No change Walking Better Worse No change Lying down Better Worse No change Rising from a chair Better Worse No change Physical activity Better Worse No change Heat Better Worse No change Don’t know Cold Better Worse No change Don’t know Massage Better Worse No change Don’t know Patient Initials___________ Date__________ Page 2 David W. Wimberley, MD PREVIOUS TREATMENT Previous treatments for this CURRENT back/neck pain Have you ever had surgery ON YOUR NECK or BACK? Chiropractic care better worse no change Physical Therapy better worse no change Yes No If YES, complete the following: Injections better worse no change Psychiatric Consultation better worse no change 1) Type of surgery: _________________________________ Other:________________ better worse no change Date_________________ Surgeon___________________ ____________________ Did it make your pain better worse no change? Please mark the timeframe for any tests that were 2) Type of surgery: _________________________________ performed for this CURRENT back/neck pain <6 months 6-12 months Date_________________ Surgeon___________________ X-ray Did it make your pain better worse no change? MRI scan CT scan 3) Type of surgery: _________________________________ Myelogram Date_________________ Surgeon___________________ Discogram EMG/NCV (nerve test) Did it make your pain better worse no change? Other Neck / Spine issues not related to today’s visit? _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Patient Initials___________ Date__________ Page 3 David W. Wimberley, MD GENERAL MEDICAL HISTORY Check all the conditions below that you currently have or have had in the past. If NONE check Heart attack Colon problems Gout Enlarged prostate Heart murmur Diabetes Anxiety Menstrual problems Angina Hepatitis Depression Caner: Type _______________ High blood pressure Cirrhosis Emphysema Osteoporosis Stroke Kidney Stones Tuberculosis Have you used: Varicose Veins Kidney infection Chronic bronchitis Immunosuppression Stomach ulcers Degenerative arthritis Frequent pneumonia Corticosteroids Duodenal problems Rheumatoid arthritis Asthma Other: ___________________ Anemia Bleeding tendency Sexual difficulty List any major surgeries you have had, other than your neck or back: Unremarkable Colon resection Mitral Valve Replacement Urinary incontinence (sling) Abdominal Surgery Craniotomy Nephrectomy (native) Vertebroplasty Amputation D&C Nephrectomy (transplant) AV Fistula creation Gastric Bypass Pacemaker Anesthesia Problem: NO AV Graft Hemorrhoid Parathyroidectomy Anesthesia Problem: YES Aortic Valve replacement Hysterectomy Peumonectomy Appendectomy Total hip arthroplasty Prostatectomy Surgical Complication: NO Bilateral Aorto-femoral bypass Interventional pain procedures PTCA (heart stent) Surgical Complication: YES Back surgery Knee arthroscopy Right Aorto-femoral bypass Bronchoscopy Knee Surgery Rotator Cuff repair Post-operative delirium CABG (heart bypass) Total Knee arthroplasty TURP Carotid Endarterectomy Kyphoplasty Tonsillectomy Carpal Tunnel Left Aorto-femoral bypass Tunneled dialysis cathether Cataract Mastectomy UPPP Cholecystecomy (GallBladder) Do you take any medication, including herbals, over the counter, and prescription? NONE TAKEN Medication Taken for Dose / how often taken Doctor (if prescribed) _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ _____________________ ________________ ___________________ __________________ Are you allergic to any medications? yes no If YES, please list: ________________________________________ ____________________________________________ ________________________________________ ____________________________________________ ________________________________________ ____________________________________________ ________________________________________ ____________________________________________ Patient Initials___________ Date__________ Page 4 David W. Wimberley, MD FAMILY MEDICAL HISTORY I do not know the Mother: Father: Number of living medical history of my Alive age:______ Alive age:______ brothers/sisters:______ biological parents or other Deceased at age:______ Deceased at age:______ Number of deceased family members. brothers/sisters:______ Due to _________________ Due to _________________ (Go on to next section) cause(s):____________ Members of my family (parents, brothers/sisters, grandparents, aunts/uncles) suffer with the following: Check all that apply Heart Trouble None of these Kyphosis Lung Disease Stroke Osteoporosis Back Problems Don’t know Arthritis High Blood Pressure Diabetes Scoliosis Cancer Other:___________________ Patient Initials___________ Date__________ Page 5 David W. Wimberley, MD SOCIAL HISTORY Marital Status Smoking Alcohol Married Current every day smoker (see A below) Do you drink: Separated Current some day smoker (see A below) Beer? yes no ____ #/day Divorced Former smoker (see B below) Wine? yes no ____ #/day Single Never smoked Hard liquor? yes no ____ #/day Widow / widower A) Frequency of drinking: Education Year Started: _____________ never Highest level completed: Cigarettes ______ packs / day rarely Grammar School Cigars ______ # per week socially (# per week _____ ) High School Smokeless / chewing ______
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