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 ? 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 ) vs extremity (arm or leg) pain: 100% Spine pain to 0% Extremity pain How bad is your ? 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 ? 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 ? 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 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? care better worse no change 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?

______

______

______

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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 attack Colon problems Gout Enlarged prostate Heart murmur Diabetes Anxiety Menstrual problems Angina Hepatitis Depression Caner: Type ______ High blood pressure Cirrhosis Emphysema 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 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: ______

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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 Disease Stroke Osteoporosis Back Problems Don’t know Arthritis High Blood Pressure Diabetes Other:______

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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 ______amount / day College daily (# per day ______) Post - graduate B) I quit smoking in / around the year ______, Do you have a history of heavy drinking? yes no But I smoked ______packs/day for _____ years.

Effect of your neck/back pain on your lifestyle Ability to enjoy life: Excellent I describe my home setting as supportive of me during this time yes no Good I describe my work setting as supportive of me during this time yes no Fair My pain has affected my interaction with my family and friends yes no Poor The changes in my lifestyle due to my problem have been difficult for me yes no

Please indicate your current work status Before having neck/back pain, did you normally work: Working full time full time part time neither Working part time What is your usual occupation? Seeking employment ______ Not working by choice (retired, homemaker, student, etc.) Do you like your work situation? Physically unable to work due to neck/back pain yes no N/A Physically unable to work not due to neck/back pain

Has your pain affected your ability to do your job or any other daily activities? yes no

If YES, please explain______

Is there anything we have failed to ask that you believe is important for us to know? yes no If YES, please explain______

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David W. Wimberley, MD

REVIEW OF SYSTEMS Have you seen a primary care physician within the past year? yes no

Do you have any of the following?

General: Cardiovascular: Recent weight loss of more than 10 lbs? yes no Chest pain yes no Recent weight gain of more than 10 lbs? yes no Shortness of breath yes no Fever? yes no Chills? yes no Respiratory: Night sweats? yes no Wheezing yes no Pneumonia yes no Chronic cough yes no

Gastrointestinal: Genitourinary: Bones/Joints: Abdominal pain yes no Abnormal kidney function yes no Shoulder pain yes no Nausea yes no Pain with urination yes no Wrist/hand pain yes no Vomiting yes no Frequent urinary infections yes no Hip pain yes no Diarrhea yes no Knee pain yes no Liver problems yes no Mental health: Lupus yes no Sleep disturbances yes no Muscle weakness yes no Skin: Feeling of hopelessness yes no Fibromyalgia yes no Open sores yes no New moles yes no Nervous system: Hematologic/Oncologic: Poor healing yes no yes no Easy bruising yes no Skin infection yes no Tremors yes no Blood thinning medications yes no Poor speech yes no Blood transfusions yes no Endocrine: Changes in vision yes no Organ transplant yes no

Thyroid problems yes no

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