Spine Surgery Questionaire

1. Name: Last: ___________________________________ First: ___________________________ MI: _____

2. Age: _________ Height: ____________Weight: ______________ Male/Female _____________

3. Who referred you? _____________________________________________________________________________

4. Your Address and Phone Number______________________________________________________________________

________________________________________________________________________________________________

5. CC: Describe your pain and where it is located: _______________________________________________________

_______________________________________________________________________________________________

6. HPI: When did you first start having pain? ____________________________________________________________

________________________________________________________________________________________________

7. Circle what caused your pain: Unknown/ Work accident/ Car accident/ Other accident/ Surgery/ Illness/ Other

8. Had you had this pain before? Yes / No When? ______________ Please explain: __________________________

________________________________________________________________________________________________

9. If your pain was caused by an accident, please give the date of the accident and describe the accident: ________________________________________________________________________________________________

10. Circle what makes your pain worse: Weather/ Physical activity/ Sitting/ Standing/ Walking/ Urination/

Bowel movement/ Sneezing/ Coughing/Other ___________________________________________________________

11. Does the pain wake you from a sound sleep? Y / N If so, how often? ____________________________________

12. Has your pain become worse recently? Yes/No When did it get worse?__________________________________

Explain why you think it became worse?________________________________________________________________

13. Do you have any areas of tingling (pins & needles) Yes / No Where?_____________________________________

14. Do you have any areas of numbness (loss of sensation)? Yes/No Where? ________________________________

15. Do you have any weakness in your arms, legs hands or feet? Yes/No Where? ___________________________

16. Circle symptoms, if any: Foot drop/ Foot slaps the floor/ Catch your toe /Drag your foot/ Other__________________

17. Circle symptoms, if any: Shuffle/ Walked stooped/ Loss of walking endurance/ Other _________________________

18. Circle treatments you have had for your pain: Physical therapy/ Chiropractic/ TENS unit/ Massage therapy/Acupuncture/ Nerve blocks/ Epidural/Pain clinic / Psychotherapy/ Surgery/ Other _________________________

19. Do you have loss of urine when you cough, sneeze or laugh? Yes______No ________

If so, how long has this been a problem for you?_________________________________________________________

20. Since your pain problem started have you developed loss of bowel or bladder control? Yes______No_________

How many times has this happened? ______________________________________________________________

When was the last time this happened? ____________________________________________________________

21. Do you have carpal Tunnel? Yes / No If so, where? ____ Right hand ______ Left hand _______ Both Hands

22. PAST MEDICAL HISTORY: Circle any of the following illnesses you have had: Hypertension/ Heart attack, heart disease/ Emphysema, bronchitis/ Depression/ Epilepsy, seizure/ Diabetes/ Cancer/ Arthritis/ Ulcers/ Stroke/ Hepatitis If so, please explain: _______________________________________________________________________________

_______________________________________________________________________________________________

23. Have you have any other illnesses? ______Yes ______No (explain)_____________________________________

24. SURGERY HISTORY: Please list ALL previous surgeries and the dates performed:

1.______________________________________________________________________________________________

2.______________________________________________________________________________________________

3.______________________________________________________________________________________________

4.______________________________________________________________________________________________

5.______________________________________________________________________________________________

Father: Alive/Deceased _____________________________________________________________________

Mother: Alive/Deceased _____________________________________________________________________

Brother/Sister: Alive/Deceased ________________________________________________________________

26. ALLERGIES: List medicines and types of reactions (nausea, itching, rash, hives, wheezing, palpitations)

1 ______________________________________________________________________________________

2.______________________________________________________________________________________

3.______________________________________________________________________________________

27. Are you presently taking COUMADIN, PLAVIX or any other blood thinners? ______Yes _____No

Medication Date Started Dosage Times per day Purpose of Medication Prescribing Doctor

1. ____________________________________________________________________________________

2._____________________________________________________________________________________

3._____________________________________________________________________________________

4._____________________________________________________________________________________

5._____________________________________________________________________________________

6._____________________________________________________________________________________

7._____________________________________________________________________________________

29. Have you ever tried to stop taking your pain medications? _______Yes _______No

30. What happened when you stopped?__________________________________________________________

31. SOCIAL HISTORY: Circle your marital status: _____Married _____Single _____Divorced ______Widowed

32. What is or was your occupation? _____________________________________________________________

33. Circle your current employment status: Working/ On sick leave/ Disabled/ Retired/ Other__________________

34. Do you smoke? _____Yes _____No If so, # of packs per day? ___ Do you chew tobacco? _____ Yes ____No

35. Do you drink alcohol? _____Yes ______No Number of drinks per week: _________ _____________________

36. Have you ever been treated for alcohol or drug abuse? Yes/No If yes, explain: _________________________

Constitutional: Weight change/ Fever/ Other______________________________________________________

Eyes: Double vision/ Blurring/ Glasses, contacts/ Other _____________________________________________

Ears, Nose, Throat & Mouth: Deafness/ Sinusitis/ Hoarseness/ Vertigo/ Other ___________________________

Cardiovascular: Chest pain/ Palpitations/ Other ___________________________________________________

Respiratory: Shortness of breath/ Asthma/ Cough/ Other____________________________________________

Stomach or Bowel: Change in appetite/ Weight change/ Pain/ Diarrhea/ Constipation/ Other ________________

Kidney/Bladder/Reproductive: Incontinence/ Pain/ Prostate/ Menstrual/Other____________________________

Muscular Skeletal: Fracture/ Sprain/ Arthritis/ Other ________________________________________________

Skin/Breast: Rash/ Scar/ Lumps/ Other _________________________________________________________

Neurological: Seizures/ Vertigo/ Memory loss/ Headache/ Other _____________________________________

Psyche: Depression/ Hallucinations/ Sleep disturbances/ Other ______________________________________

Endocrine: Growth/hair changes/ Thirst/ Energy loss/ Other _________________________________________

Hematologic/Immunologic: Bruising/ Blood clots/ Bleeding/ Other ____________________________________

Explanations (if necessary) __________________________________________________________________

________________________________________________________________________________________

38. Is your injury workman’s comp related? _____Yes _____No Automobile insurance related? _____Yes _____No

39. Is there litigation pending with your injury? _____Yes _____No If so, who is your lawyer? ___________________

40. Do you want us to share information with your lawyer if he contacts us? ______Yes ______No Initials, if yes: ____

Thank you for completing this questionnaire. At MicroSpine you will undergo an evaluation to determine the source of your pain and the treatment options available. Depending upon our assessment of your problem, our pain management staff, or our surgical staff, or both, may treat you. We will make every attempt to fully explain our findings and your options. Whether you require surgery or pain management services, you should be aware there are risks involved when undergoing medical procedures. Possible complications vary from procedure to procedure, but may include infection, nerve injury, headache, nausea, bleeding, and, very rarely, loss of life or limb. These complications are uncommon, but we want you to be an informed patient.