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)