NEW HAVEN by alicejenny

VIEWS: 3 PAGES: 4

									                                                                 CT SPINE INSTITUTE FOR
                                                                 MINIMALLY INVASIVE SURGERY



                  NEW PATIENT QUESTIONNAIRE
                                       (SPINAL / CRANIAL)
         PLEASE READ AND COMPLETE THE FOLLOWING QUESTIONNAIRE TO THE BEST OF YOUR ABILITY.
   WE HOPE THAT BY DOING SO, YOUR VISIT AND EXAMINATION WILL BE MORE PRODUCTIVE AND COMPLETED IN A TIMELY FASHION.
PATIENT NAME: ____________________________________________________________
AGE: _______          D/O/B:       /    /    HEIGHT:          feet      inches WEIGHT:                   lbs.
HOME: (       )                    WORK: (         )                    EMERGENCY: (               )

EMPLOYER & Address: __________________________________________________
OCCUPATION: ____________ ❑ are you currently working? ❑       Full-time? ❑Part-time?
WORK STATUS: ❑      Light-duty ❑Other Restrictions ❑ Retired
Injury Date: / / Date last worked _ / /      Who took you out of work?: ____________
* * * PLEASE STATE CAUSE IF KNOWN * * *
❑ Work injury ❑ MVA ❑   Other injury involving an Attorney
Case Manager: ____________________
      Address: ____________________          Attorney Name: _____________________
               ____________________                Address: __________________ ___
               ____________________                          _____________________
   Phone: ( )_____________________                    Phone: (__)__________________
  CLAIM #: ______________________
  ___________
REFERRING
PHYSICIAN:_____________________


PRIMARY CARE

Any other physicians involved in your care: _________________________________
                                  Address: _________________________________
                                            _________________________________
                                   Phone:(___) _____________________________

CURRENT MEDICAL CONDITION:
1. What is the Main Reason for your Neurosurgical Consultation today? _____________________________
_______________________________________________________________________________________
2. WHAT symptoms are you having? ________________________________________________________
_______________________________________________________________________________________
3. WHEN did your symptoms begin? ________________________________________________________
_______________________________________________________________________________________
4. HOW did your symptoms begin? _________________________________________________________
_______________________________________________________________________________________
5. Have you had any previous treatment for these symptoms? ❑  YES ❑   NO
IF YES, with Whom, When & What was done? ________________________________________________
_______________________________________________________________________________________
Patient Name: ______________________________________________                                Page 2
MEDICAL HISTORY:                                  SURGICAL HISTORY:
  (Medical Problem)         (Treating Doctor)        (Procedure)          (Surgeon)     (Date)
1. _______________________________________        1. _______________________________________
2. _______________________________________        2. _______________________________________
3. _______________________________________        3. _______________________________________
4. _______________________________________        4. _______________________________________



MEDICATIONS: (Please list ALL current medications and doses)
Medication Name                     Dosage (mg.) How often?        Prescribed By (Doctor Name)
_________________________________   ___________   ______________   _______________________________
_________________________________   ___________   ______________   _______________________________
_________________________________   ___________   ______________   _______________________________
_________________________________   ___________   ______________   _______________________________
_________________________________   ___________   ______________   _______________________________
_________________________________   ___________   ______________   _______________________________
_________________________________   ___________   ______________   _______________________________




ALLERGIES or REACTIONS:
Medications: 1. ______________________ 2. _________________ 3. _________________
              (Include reactions such as rash, redness, itching, bloating, etc.)
Non-Medications: 1. __________________2.__________________ 3. _________________
              (Foods, dyes, dust, animals, etc. w/reactions)

SOCIAL HISTORY:
❑ Married, Spouses Name __________________ ❑ Significant other _________________ ❑
Single ❑ Divorced ❑ Separated ❑ Widowed

Do you smoke Tobacco? ❑YES ❑  NO Do you drink alcoholic beverages? ❑YES ❑ NO
What type? ________ How much? _____ What type? _______ How much a day? _______
When did you start smoking (age)? ________

FAMILY HISTORY:
Mother: Age _____ ALIVE? ❑    YES ❑NO Medical Problems? ______________________
Father: Age _____ ALIVE? ❑    YES ❑NO Medical Problems? ______________________
❑ Brothers ❑ Sisters ❑ Children       Medical Problems? ______________________

Describe any family members with similar medical problems/symptoms for which you are
being evaluated today? ________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
RADIOGRAPHIC STUDIES: (studies relevant to the reason you are seeking treatment)

X-rays    ❑YES ❑NO
CAT Scan ❑ YES ❑NO
MRI      ❑ YES ❑NO
Other    ❑YES ❑ NO

DATE :
                                     FACILITY / PHYSICIAN:

REVIEW OF SYSTEMS:
Please check all of the following symptoms that pertain to you ...

1. Constitutional Symptoms: ❑ Weight Gain ❑ Weight Loss ❑ Exercise intolerance
2. Eyes: ❑Blurred or double vision ❑Visual loss
3. Ears, Nose, Mouth and Throat: ❑    Hearing loss ❑Ringing in ears/vertigo ❑ Difficulty
   swallowing ❑Hoarseness of voice ❑ Headache ❑ Nose bleeds ❑ Neck pain, stiffness ❑
   Dizziness
4. Cardiovascular: ❑ Chest pain❑ Shortness of breath: ❑ ... at rest ❑ ... on exertion ❑
   Palpitations ❑ Leg swelling ❑ Heart murmur
5. Respiratory: ❑ Shortness of breath ❑ Difficulty breathing ❑ Wheezing ❑ Cough ❑ Fever
   ❑ Night sweats
6. Gastrointestinal (Stomach Problems): ❑ Decreased Appetite ❑ Difficulty swallowing
    ❑ Abdominal pain ❑ Nausea/vomiting ❑ Stomach Ulcers ❑ Stool seepage ❑ Constipation
7. Genitourinary (Urinary Problems): ❑Urgency ❑Frequency ❑Inability to void
    ❑Incontinence ❑Pain with urination ❑ Bloody urine ❑ Sexual dysfunction (impotence)
8. Musculoskeletal: ❑ Pain ❑ Swelling of arms/legs ❑ Weakness ❑ Loss of muscle mass/
   bulk ❑ Cramps
9. Skin / Breast: ❑ Itching ❑ Rash ❑ Change in hair growth ❑ Breast lumps, discharge,
   tenderness
10: Neurological: ❑ Tremors ❑ Memory disturbance ❑ Slurred Speech ❑ Numbness             ❑
   Weakness ❑ In-coordination/unsteadiness ❑ Difficulty walking ❑ Seizure
11: Immunological/Endocrine: ❑ Anemia ❑ Prior Transfusions ❑ Cold or heat intolerance
   ❑ Excessive thirst ❑ Excessive urination
Please elaborate on any of the above if being treated by a physician:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Patient Signature: ____________________________Physician Signature: _______________________
                            SPINE PATIENTS ONLY
SYMPTOMS:
If you have Back, Leg. Neck or Arm Pain:
How often do you have pain: ❑   Rarely ❑ Daily ❑  Continuously ❑  Under certain circumstances
Is your pain worse with any of the following ...
❑  Prolonged standing ❑ Bowel movement ❑ Sneezing ❑       Coughing
❑  Prolonged sitting ❑ Sexual activity ❑Bending ❑Other activity or position: ______________
Does rest relieve it? ❑ YES ❑   NO …lying down? ❑       YES ❑    NO …standing? ❑     YES ❑   NO
If you have NECK pain, does it extend to shoulders and/or arms? ❑  YES ❑    NO
Where? ____________________________________________________________________
If you have BACK pain, does it extend to the buttocks and/or legs? ❑YES ❑    NO
Where?____________________________________________________________________________
How would you describe the pain?
❑  Aching ❑ Throbbing ❑  Sharp ❑  Burning ❑  Spasm ❑  Other ________________

What makes the pain worse? ___________________________________________________________

What makes the pain feel better? _______________________________________________________
Is your pain at its worst now? ❑YES ❑  NO
Mark your recent average pain level on this line: (0=no pain, 10=worst pain ever)
0                                                                                     10



TREATMENT                       How long or     Date of last   Was treatment helpful?
                                how many        treatment:
HISTORY:                        treatments?
Chiropracter ❑YES ❑NO           _______
Physical therapy ❑YES ❑NO
Aquatic Therapy ❑YES ❑NO
Pain Management ❑YES NO
Injections:
Epidural
Facet
Trigger Point


TENS Unit
Brace ...
OTHER (e.g., Massage,
Acupuncture)

								
To top