Spine Patient History Please Complete ALL Information

Today's Date: Name: Age: D.O.B.: Occupation: Referring Doctor: Primary Doctor: Marital Status:    Single    Married    Divorced    Widowed CHIEF COMPLAINT: Explain why are you here to see the doctor, or how the injury occurred.

HISTORY OF PRESENT ILLNESS: How long have your symptoms been present?   Do you have: (Mark all that apply)   Pain Numbness/Tingling Weakness Back Leg ( Left   or  Right) Neck Arm ( Left   or  Right) Other How does this problem affect you? How severe is your pain?  1  2  3  4  5  6  7  8  9  10  Wakes you up at night  Interferes with work activities  Interferes with recreational activities Was this the result of an accident?    Yes     Date: Is there any litigation pending?    Yes   Did your injury occur at work?    Yes   Have you had any of the following tests for this problem?  X-rays  CT Scan/Myelogram  MRI  EMG/NCV (nerve test)  Other   Have you ever had any surgery on your neck/back?    Yes     When: What type of surgery did you have?   Has surgery been recommended to you?    Yes    No Please list all surgeries (with type and date) What treatments have you had for your symptoms?  Epidural  Physical Therapy  Narcotic Pain Medication  Over the Counter Pain Medication  Chiropractic Treatments  Other Please list all medications and dosages: Allergies: MEDICATIONS: List all current medications, including over-the-counter drugs and diet supplements ALLERGIES: List all drug allergies PAST MEDICAL HISTORY: Please check ALL that apply CARDIOVASCULAR  Heart Attack  High Blood Pressure  Arrhythmia  Pacemaker  Heart Failure  Heart Surgery  Heart Murmur RESPIRATORY  Asthma  Bronchitis  Emphysema/Cardiopulmonary disorder  Sleep Apnea MUSCULOSKELETAL  Osteoarthritis  Rheumatoid Arthritis  Gout  Lupus  Osteoporosis  Other HEPATIC  Hepatitis  A  B  C NEUROLOGIC  Stroke  TIA ENDOCRINE  Diabetes  Thyroid Disease  Hyper  Hypo  Adrenal Abnormality CANCER  List Type GASTROINTESTINAL  Ulcers  Acid Reflux SOCIAL HISTORY: Do you smoke?    Yes    No If so:   How many years?   Packs per day?   Are you smoking now?  Yes    No Do you have a family history of:    Cancer    Heart Disease    Diabetes    Scoliosis Do you drink?    Yes   If so, how often?    None     Occasionally     A drink with dinner     More than I should  REVIEW OF SYSTEMS: Please check ALL that apply GENERAL  Weight gain  Weight loss  Fever  Chills HEAD/NECK  Blurry vision  Sore throat  Trouble swallowing  Loss of hearing CARDIOVASCULAR  Chest pain  Skipped heart beats NEUROLOGIC  Dizziness  Numbness/Tingling  Weakness  Headaches SKIN  Unusual Rashes  Psoriasis RESPIRATORY  Shortness of breath  Sleep apnea  Cough  Wheezing GASTROINTESTINAL  Abdominal pain  Nausea/Vomiting  Diarrhea/Constipation  Bloody stools  Indigestion GENITOURINARY  Pain in urination  Inability to urinate  Involuntary urination MUSCULOSKELETAL  Joint Swelling  Joint Stiffness  Joint Pain I certify that, to the best of my knowledge, all information listed above is true. I further certify that I have not misstated or intentionally omitted any information related to my health or past medical history. Date Click checkbox to electronically sign (patient/guardian)