PATIENT SPINE INTAKE FORM NAME___________________________________ APPOINTMENT DATE____________________________ Chief Complaint: (What is the problem? Example: back pain, neck pain, etc.): _________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ History: (How and when did your problem begin?) __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ Please indicate any treatments you have had so far: (Check all that apply) ____None ____Injections ____Physical Therapy (how long and where) __________________________________ ____Surgery (when and where) _____________________________________________________________________ ____Medications (for this problem) __________________________________________________________________ Please categorize your pain: (Please circle one) none mild moderate moderate to severe My pain is: (Please circle all that apply) deep superficial severe mild to moderate unbearable constant intermittent improving worsening achy burning Using the symbols given below, mark the areas on the body where you feel the described sensations. Include all affected areas. NUMBNESS X PINS AND NEEDLES BURNING / STABBING = ACHE < 0 Modifying factors (What makes your pain better or worse? Please check all that apply) ____Better with activity ____Better with sleep ____Worse with activity ____Worse with sleep ____Better with rest ____better with medicines ____Worse with rest ____Nothing ____Changing positions help (describe):________________________________________________________ Past Medical History (Please check all that apply): ____arthritis ____coronary disease ____high blood pressure ____cancer ____excessive bleeding ____fibromyalgia ____heart attack ____GERD ____anemia ____DVT (clots) ____NEGATIVE ____gout ____arrhythmia ____ulcers ____diabetes ____osteoporosis ____hearing loss ____stroke ____asthma ____COPD ____thyroid disease ____hepatitis ____colitis ____neuropathy ____pulmonary embolism Past Surgical History (Please list any prior surgeries and approximate dates): _____NEGATIVE ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ If you have had surgery, have you had any problems with anesthesia? Please explain:____________________________ ________________________________________________________________________________________________________ Do you have any of the following problems? (Please check all that apply) _____NONE ____recent weight loss or gain ____skin rashes ____sore or dry throat ____chest pains or tightness ____nausea or vomiting ____pain in multiple joints ____burning with urination ____mood swings ____fever/chills ____headache ____shortness of breath ____heart palpitations ____heartburn (reflux) ____difficulty with urination ____swelling in arms or legs ____dizziness/balance problems ____blurred vision ____hearing loss ____chronic cough ____abdominal pains ____body aches ____constipation/diarrhea ____depression ____skin bruising Family History (Does anyone in your family have a history of the following?) Please check all that apply: ____arthritis ____stroke ____coronary disease ____heart attack ____high blood pressure ____GERD ____cancer ____anemia ____substance abuse ____DVT (clots) ____osteoporosis ____hearing loss ____mult. fractures ____arrhythmia ____asthma ____COPD ____ulcers ____thyroid disease ____hepatitis ____diabetes ____colitis ____neuropathy ____pulmonary embolism ____anesthesia problems Social History: (Please check the appropriate space): Smoking History If yes DIAG CODE 305.1 Smoked at least 100 cigarettes in your life? ____Current Every Day Smoker ____Current Same Day Smoker ____Former Smoker Yes No ____Smoker, Current Status Unknown ____None of the above ____Not Asked Details Cigarettes per day _____ Do you use smokeless tobacco? Years smoked_____ Yes No Are you at risk for secondhand smoke? Yes No Comments: ___________________________________________________ Alcohol Use ____none ____socially ____daily. If daily, how much and what do you drink?______________________________________________________________________________ Recreational Drugs Please list any recreational drug use_____________________________________________ History of substance abuse? ____No ____Yes. Explain__________________________________________ ____________________________________________________________________________________________ Drug Allergies (Please check or list others): ____NONE ____penicillin ____keflex or cephalosporins ____sulfa ____IVP dye ____aspirin Others:_______________________________________________________________________ ________________________________________________________________________________________________________ Current Medications (PRINT CLEARLY and list all medications or supply us with a separate list): ____NONE _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ Please list your height and weight: Height_______ Weight_ DO NOT WRITE BELOW THIS LINE Smoking Plan ____Advised to quit tobacco use _____Cessation Vital Signs ____Cessation materials/counseling provided pharmacologic therapy provided Blood Pressure _________/ _________ Position: Sitting-Standing-Lying Location: _____Left Arm ____Right Arm Taken by ____________ Educational Materials ____BMH Information ____Surgery Center Instructions/Information ____Home Exercise Program Notes: (for office use only):_______________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ PHYSICAL EXAM: Range of Motion Spine LUMBAR Flexion ______ Extension ______ Sbr ______ Sbl ______ Rotr ______ Rotl ______ PE>PF, PF>PE, PE=PF NP P NP P Flexion Extens. NP P NP P KNEE ROM – R or L Effusion Calor Rubor AP Inst. ML Inst. Med. Lat. Joint Line Tenderness Med. Lat. Meniscus Provocative CERVICAL ______ ______ RotR. RotL PE>PF, PF>PE, NP P NP P ______ NP P ______ NP P PE=PF SHOULDER R or L ______ ______ Int.Rot. ______ Ext.Rot. ______ Direct Impingement Indirect Impingement Bicipital Tendinitis Flexion Abduct TENDER POINTS R R R R NEUROLOGIC: Motor ________________________ Sensory ______________________ Tone ________________________ Atrophy _____________________ Plantar Response R ___ or L ___ Ankle Clonus R ___ or L ___ Hoffman R ___ or L ___ Distal Pulses Lower Extremity R ___ or L ___ L L L L Lumbar SI SN GTB Thoracic Cervical Prox. Shoulder Right Bicep ______ Brachoradialis ______ Triceps ______ Patella ______ Achilles ______ Fasciculations Dysdiokinesis Rhomberg Left ______ ______ ______ ______ ______ Straight Leg Raise R ___ or L ___ 9-15-11
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