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
Alcohol Use
____none ____less than one pk/day
____one pk/day
____two pks/day
____more than two pks/day
____prior smoker who quit…..when? ________
____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 (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
Notes: (for office use only):_______________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
PHYSICAL EXAM:
Range of Motion Spine
LUMBAR
Flexion
______
Extension
______
Sbr
______
Sbl
______
Rotr
______
Rotl
______
PE>PF, PF>PE, PE=PF
CERVICAL
Flexion
______ NP
Extens.
______ NP
RotR.
______ NP
RotL
______ NP
PE>PF, PF>PE, PE=PF
NP P
NP P
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
P
P
P
P
SHOULDER R or L
Flexion
______
Abduct
______
Int.Rot.
______
Ext.Rot.
______
Direct Impingement
Indirect Impingement
Bicipital Tendinitis
TENDER POINTS
R
R
R
R
L
L
L
L
Lumbar SI SN GTB
Thoracic
Cervical
Prox. Shoulder
NEUROLOGIC:
Right
Left
Motor ________________________
Sensory ______________________
Tone ________________________
Atrophy _____________________
Plantar Response R ___ or L ___
Ankle Clonus
R ___ or L ___
Hoffman
R ___ or L ___
Bicep
______
______
Brachoradialis
______
______
Triceps
______
______
Patella
______
______
Achilles
______
______
Fasciculations Dysdiokinesis
Rhomberg
Distal Pulses Lower Extremity R ___ or L ___
Straight Leg Raise R ___ or L ___