Microsoft word - new patient questionnaire bermuda
Bermuda Spine Center
NEW PATIENT QUESTIONNAIRE
Name:________________________________________________Age: ____________ Date of birth:_______________
Who referred you to our office?______________________________________________________________________
When did your problem start? ________________ Instructions
: Only complete sections A-G below that apply to you. There will be a General Medical section that will
need to be completed in full and starts on page 6.
INJURY OR TRAUMA (Section A)
Did a particular accident or injury cause your problem?
□ No (please skip to Section B)
Check only one: □ I never had back/neck problems in this area of my spine before this injury. □ I had back/neck problems in this area of my spine before, and this injury made the problem worse. Check all that apply: □ This injury occurred at work. □ I have filed a claim through workers compensation. DO NOT WRITE BELOW THIS LINE. (Continue questionnaire on page 2)
PAIN, NUMBNESS, AND DISABILITY: (Section B)
This section pertains to pain or Numbness
Does your neck or back problem cause pain?
□ Yes (Continue this section) Mark your pain
on the fig below.
□ No (please skip to section C)
□ Yes (continue this section) Mark your numbness below
Please mark on the figure below to show where you feel pain using a X mark.
Please mark on the figure below to show where you feel Numbness using a # mark.
Pain scale 0-10 (0= No pain, 10= pain severe enough to pass out)
What number would you give your pain today? _________
What number would you give your pain on average? _________
What number would you give your pain at its worse? _________ Please check all that describe your pain:
Please check all of the appropriate responses in each category to complete the phrase “ My pain… “
□ began suddenly
My pain is worse…….
□ during the day
My pain is worse when………….….
□ applying heat □ applying ice □ exercising
□ Frequently changing positions □ Lying
□ sports (list)_____________________________________ □ Over head activity
□ Nothing makes my pain worse
My pain is better while………….….
□ applying heat □ applying ice □ exercising
□ Frequently changing positions □ Over head activity
□ Lying on Back □ Lying on Side □ Lying on Stomach
□ Nothing makes my pain better
Overall, which single word or phrase would you use to describe your pain the majority of the time?
Because of my pain, I am unable to………….
□ Walk over _______miles
□ Sit longer than ______min/hrs (circle one)
□ Stand longer than _____min/hrs (circle one)
SPINAL DEFORMITY/TUMOR (Section C)
Do you have a curve, lump, or mass near or on your spine?
□ No (please skip
to section D)
Please check all that apply to your situation.
□ I have a spinal curvature or deformity (scoliosis or kyphosis) that was present at birth
□ I have a spinal curvature or deformity (scoliosis or kyphosis) that developed in childhood
, and was not present
□ I have a spinal curvature or deformity (scoliosis or kyphosis) that developed as an adult
, and was not present in
□ I wore a brace when I was younger to help my scoliosis or kyphosis
□ I am wearing a brace now
□ I have noticed my spinal curvature getting worse
□ My clothes no longer fit or hang properly
□ I have a lump or mass on my spine that is getting larger
□ I have a lump or mass on my spine that is not getting larger
□ The mass is painful
□ The mass is not
ASSOCIATED PROBLEMS (Section D)
Please check all that apply to you
□ Leakage of bowel contents or staining underwear
□ Leakage of Urine or staining underwear
□ Unable to completely empty your bladder
□ Unable to look forward without bending knees
□ I HAVE NONE OF THE ABOVE PROBLEMS
TESTING AND TREATMENT (Section E)
Which of the following tests have you had in the last year for your spine problem? (check all that apply)
□ Other ________________________________________________________________
□ I HAVE HAD NO TESTS TO EVALUATE MY PROBLEM
Your treatment history (Please check all that apply)
Complete Improved Unchanged Worse relief
Epidural Steroid Injection (performed in the Hospital)
Facet Joint Injection (performed in the Hosp)
Local or Trigger Point Injection (performed in the office)
I HAVE NOT STARTED OR COMPLETED ANY OF THE ABOVE TREATMENTS
Please list all medication you have tried RELATED ONLY FOR YOUR SPINE
, the dose, and the number of pills used
per day for this problem.
= naproxen, voltaren, ibuprofen, vicodin, percocet, oxycontin, darvocet, morphine, soma, flexeril, robaxin,
baclofen, celebrex, vioxx, bextra. etc)
PRIOR SPINE SURGERY (Section F)
Have you ever had surgery on your spine?
(This includes Fusions, decompressions, or any disc procedures)
Rate the outcome of surgery Poor, good or excellent (See Legend below)
Legend: Poor = the surgery had no change or made me worse
Excellent = Dramatically improved or resolved my symptoms
General Medical Section
(Complete all areas below)
Please check or circle any medical problem you currently have, or have experienced in the past.
No medical problems
What medications do you take for problems UNRELATED to your spine?
Please list all non-spine related surgeries:
Please list all the Doctors you have seen in the last 2 years:
□ I do not know of any allergies or reactions to any medication □ I am allergic to (Please circle and give
Please check next to any medical problem that runs in your family. Diabetes(Sugar)
Stomach Ulcers or Reflux disease (Peptic ulcer,
There are no medical
problems in my family
What is your current occupation?_________________________________________________________________
How long? _______________ Please check all that apply to your work or school status:
□ I have missed no time from work or school because of my spine problem □ I am currently working full time □ I have missed a total of ______ days from work or school because of my spine problem □ I am working
□ I am unable to work at all because of my spinal problem □ I am unable to work at all because of another problem not related to my spine (diagnosis) ________________ □ The last date I worked was: _______________________ □ I have been receiving worker’s compensation since ________________________ □ I have been on disability since _______________________
What is your marital status?
Single Married Separated Divorced Widowed
What is your living situation?
List your recreations or sports with frequency and duration.
Please check all that apply to you:
□ I never smoked cigarettes
□ I quit smoking ________years/months ago
□ I smoke cigarettes at __________packs per day
□ I have smoked for __________years
□ I chew tobacco
□ I never drink alcohol
□ I drink alcohol
□ I am recovering from a drinking problem □ Recreational drug use □ I have not, nor do I plan to take legal action related to this injury. □ I am considering or have taken legal action as a result of this injury. □ Legal action related to this injury is closed or settled.
REVIEW OF SYSTEMS
Please check all problems below that apply to you.
Bowel Incontinence (Uncontrolled defication)
Thank you for completing the questionnaire. It will be incorporated into your initial evaluation.
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