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Spine Questionnaire 2020

This document contains a pain assessment form for a patient. It collects information about the patient's pain levels and locations, pain history and treatments, medical history, medication use, and social history. The form asks the patient to mark diagrams of the body to indicate where they feel pain, numbness, or tingling. It asks about the onset of pain, potential causes, and effectiveness of prior treatments. It inquires about symptoms, allergies, and family medical histories. Finally, it collects social information like tobacco, alcohol and drug use, education, occupation, disability status, and physicians.

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roxie
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76 views5 pages

Spine Questionnaire 2020

This document contains a pain assessment form for a patient. It collects information about the patient's pain levels and locations, pain history and treatments, medical history, medication use, and social history. The form asks the patient to mark diagrams of the body to indicate where they feel pain, numbness, or tingling. It asks about the onset of pain, potential causes, and effectiveness of prior treatments. It inquires about symptoms, allergies, and family medical histories. Finally, it collects social information like tobacco, alcohol and drug use, education, occupation, disability status, and physicians.

Uploaded by

roxie
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 5

~

~ NYU Langone
' - - MEDICAL CENTER

Age: _ _ _ _ _ _ _ Height: _ _ _ _ _ _ _ Weight: _ _ _ _ _ __

PAIN INFORMATION
Mark all the areas on your body where you feel the described sensations. Also mark the areas of
radiation. Include all affected areas:

Pain:\\\\\\

Numbness: 000000

Tingling: xxxxxx
•

Where do you have pain?

Neck _ __ Upper Back _ __ Lower Back _ __

Right Arm _ __ Left Arm _ __ Right Leg _ __ Left Leg _ __

When did the pain first begin? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Is your current pain a result of a: Car Accident_ __ Fall- - - Work Injury__ __

Other (Please explain):

Draw a mark on the line to best describe your pain:


Your pain right now: 0 ' - - - - - - - - - - - - - - - - - ' 10
no pain worst pain

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Have you had the following done for your pain problem?
Was it successful?
Physical therapy/active exercise _yes - no _yes - no
Heat _yes no _yes no
- -
Cold _yes - no _yes - no
Manipulation (chiropractor) _yes no _yes no
- -
TENS Unit _yes - no _yes - no
Pain psychology _yes - no _yes - no
Holistic alternative medicine _yes no _yes no
- -
Spinal injections (number:_) _yes - no _yes - no
Surgery (type:_) _yes - no _yes - no

MEDICATION INFORMATION

Have you had any of the following:


Unplanned weight loss? (pounds:_ _ ) _yes - no
Weight gain? (pounds:_ _ ) _yes no
-
Night sweats? _yes - no
Flu-like symptoms? _yes - no
Trouble controlling your bladder? _yes - no
Trouble controlling your bowels? _yes - no
Bladder infections? _yes - no
Stomach pains or heartburn? _yes - no
Constipation? _yes - no
Persistent diarrhea? _yes - no
Chest pain or angina? _yes - no
Blueness or blackness in fingers or toes? _yes - no
Numbness in fingers or toes? _yes - no
Easy bruising? _yes - no
Shortness of breath? _yes - no
Skin problems? _yes - no
Skin color changes? _yes - no
Excessive hair loss? _yes - no
Changes in vision? _yes - no
Changes in hearing? _yes - no
Changes in swallowing? _yes - no
Excessive thirst? _yes - no
Frequency of urination? _yes - no
Sexual dysfunction? _yes - no
Allergic reactions? _yes - no
When was your last menstrual period?_ _ _ _ _ _ _ _ _ __ _yes - no

I am allergic to:

reaction: _ _ _ _ _ _ __

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reaction: _ _ _ _ _ _ __

Please circle if you take: Aspirin 81mg Aspirin 325mg Ibuprofen (Motrin, Advil) Naprosyn (Aleve) Celebrex

Please list all current medications/vitamins/supplements and doses:


Drug Dose Frequency Reason for Taking

PAST MEDICAL HISTORY

Please circle any of the following which you have had:

Heart Attack High Blood Pressure Heart Murmurs Palpitations

Heart Disease High Cholesterol Stroke Seizures

Diabetes Thyroid Disease Asthma Emphysema

Tuberculosis Ulcers Heartburn (GERO) Hepatitis (type: _ _)

Cirrhosis Gallstones Kidney Stones Urinary Urgency

Urinary Incontinence Urinary Retention Prostate Enlargement Gout

Arthritis HIV Infection AIDS Depression

Anxiety Panic Attacks Hemophilia Bleeding Abnormalities

Cancer (type: Other:

Please list all previous operations:

Surgery Right/Left Side Date

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Has anyone in your immediate family (mother, father, siblings, children) ever had:

Yes Who
1. A bleeding disorder or hemophilia?
2. A heart attack?
3. Heart disease ?
4. Diabetes mellitus?
5. A stroke?
6. Rheumatoid arthritis?
7. Lupus?
8. Cancer? type: _ _ _ _ __
9. Spine surgery?
10. Chronic lower back or neck pain?

SOCIAL HISTORY

Tobacco: _ _ packs daily for _ _years _ _ do not smoke

Alcohol Intake: _ _ none _ _every day _ _ 1-2 times/week _ _ 1-2 times/month


Type: _ _ _ _ _ _ _ __ how much:
----------
Recreational Drugs: none _ _every day 1-2 times/week 1-2 times/month
_ _ Past use Type:---------

Your highest e d u c a t i o n : - - - - - - - - - - - - - - - - - - - - -

Your o c c u p a t i o n : - - - - - - - - - - - - - - - - - - - - - - - -

Are you presently working? _ _ Yes _ _ No

If yes, please check one that applies:


Full time with no restrictions
_ _ Full time with restrictions
_ _ Part time with no restrictions
Part time with restrictions
_ _ Homemaker
_ _ Unemployed (not due to injury)- how long? _ _
_ _ Unemployed (due to injury)- how long? _ _
_ _ Retired
_ _ Disability

Have you attempted to return to work since the onset of pain? _ _ Yes _ _ No

Do you receive Social Security benefits? _ _ Yes _ _ No

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Do you receive Worker's Compensation benefits? _ _ Yes _ _ No

Have you been or do you plan to be involved in legal action regarding your pains? _ _ Yes _ _ No

Please list your physician's first & last name and phone number:

Primary P h y s i c i a n : - - - - - - - - - - - - - - - - - - - - - - - - - - -

Cardiologist:------------------------------

Neurologist: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Pain Management P h y s i c i a n : - - - - - - - - - - - - - - - - - - - - - - - -

Page 5 of 5

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