NAME: ____________________________________ Birth Date: ____________________________
Sex: M or F (circle) Race: _________ Ethnicity: ___________ Primary Language_____________
Current Height: __________________________ Weight: ___________________________________
Chief Complaint: ___________________________________________________________________
When did your spine problem first begin? ________________________________________________
Did your pain start because of an:
Accident at work
Motor vehicle accident
If there was an accident, what caused the pain ._____________________________________________
Workers Compensation Claim? [ ] Yes [ ] No
Do you have any problems controlling your bowel and / or bladder? [ ] Yes [ ] No
Hand dominance:
Right
Left
Mark the areas of your body where you feel pain, numbness or weakness. Use the appropriate symbol.
Numbness or pins/needles
Aching or cramping
Muscle weakness
OOOOOOOOOOO
XXXXXXXXXXXXX
++++++++++++++
Right
Left
Left
Right
Page 2 of 7
Oregon Spine Care.
NEW NECK PAIN: Circle all those that apply
Chief Complaint:
Neck
Headache
Right Shoulder Left Shoulder
Overall Neck Pain: 1…2…3…4…5…6…7…8…9…10
Right Upper Extremity
Left Upper Extremity
Overall Upper Extremity Pain: 1…2…3…4…5…6…7…8…9…10
Neck pain: choose most applicable:
Neck pain > Upper extremity pain
Upper extremity pain > neck pain
NECK PAIN
Aching
Burning
Stabbing
Throbbing
Tingling
ARM PAIN QUALITY
Aching
Burning
Stabbing
Throbbing
Tingling
Constant
Intermittent
Constant
Intermittent
Gradually Worsening
Rapidly Worsening
Gradually Improving
Rapidly Improving
Gradually Worsening
Rapidly Worsening
Gradually Improving
Rapidly Improving
Upper extremity pain = neck pain
NUMBNESS
WEAKNESS
None
Right Shoulder
Right Arm
Right Forearm
Right Thumb
Right Long Finger
Right Small Finger
None
Right Shoulder
Right Arm
Right Forearm
Right Thumb
Right Long Finger
Right Small Finger
Left Shoulder
Left Arm
Left Forearm
Left Thumb
Left Long Finger
Left Small Finger
Left Shoulder
Left Arm
Left Forearm
Left Thumb
Left Long Finger
Left Small Finger
NEW BACK PAIN: Circle all those that apply
Chief Complaint:
Mid-Back
Low Back
Sacrum Right Buttock
Overall Back Pain: 1…2…3…4…5…6…7…8…9…10
Left Buttock
Right Lower Extremity
Left Lower Extremity
Overall Lower Extremity Pain: 1…2…3…4…5…6…7…8…9…10
Back pain: choose most applicable:
Back pain > lower extremity pain
Lower extremity pain > back pain
BACK PAIN QUALITY
Aching
Burning
Stabbing
Throbbing
Tingling
LEG PAIN QUALITY
Aching
Burning
Stabbing
Throbbing
Tingling
Constant
Intermittent
Constant
Intermittent
Gradually Worsening
Rapidly Worsening
Gradually Improving
Rapidly Improving
Gradually Worsening
Rapidly Worsening
Gradually Improving
Rapidly Improving
The symptoms are better with:
Rest
The symptoms are worse with
Bending forward
Lower extremity pain = back pain
NUMBNESS
Left Buttock
Left Anterior Thigh
Left Knee
Left Shin
Left Top of Foot
Left Bottom of Foot
WEAKNESS
Left Buttock
Left Hip
Left Thigh
Left Ankle
Left Big Toe
Left Calf
Right Buttock
Right Anterior Thigh
Right Knee
Right Shin
Right Top of Foot
Right Bottom of Foot
Right Buttock
Right Hip
Right Thigh
Right Ankle
Right Big Toe
Right Calf
Lying down
Bending backward
Bending forward
Sitting
Bending backward
Standing/Walking
Page 3 of 7
Oregon Spine Care.
Treatments
Physical Therapy
[ ] never tried
Dates______________
[ ] helpful [ ] not helpful
Last treatment _____________ Where_______________
What treatment was performed? [ ] exercises [ ] stretching [ ] TENS unit [ ] ultrasound [ ]massage
Spine Injections
[ ] never tried
Dates______________
[ ] helpful [ ] not helpful Last treatment _____________ Where_______________
Acupuncture
[ ] never tried
Dates______________
[ ] helpful [ ] not helpful Last treatment _____________ Where_______________
Chiropractics
[ ] never tried
Dates______________
[ ] helpful [ ] not helpful Last treatment _____________ Where_______________
Oral steroids
[ ] never tried
Dates______________
[ ] helpful [ ] not helpful Last treatment _____________ Where_______________
Medications – Attach sheet if necessary
Medication
Strenght/Directions
Allergies– Attach sheet if necessary
Medication/Other Allergy
Reaction
Please list any spine surgeries [ ] NONE
Lumbar
1
2
Type of Surgery
Cervical
1
2
Type of Surgery
Date
Surgeon
Date
Surgeon
Helpful
Yes No
Yes No
SX
Helpful
Yes No
Yes No
SX
Please check / list all operations: [ ] none
[ ] Appendectomy
When:_______________________
[ ] Tonsillectomy
When:_______________________
[ ] Gall bladder removal
When:_______________________
[ ] Knee arthroscopy
When:_______________________
[ ] Knee replacement
When:_______________________
[ ] Hip replacement
When:_______________________
[ ] _______________
When:_______________________
[
[
[
[
] Eye Surgery
] Heart surgery
] Hysterectomy
] Prostate surgery
[ ] Surgery for cancer
[ ] _______________
[ ] _______________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
When:_______________________
Page 4 of 7
MEDICAL HISTORY
Please check the box if you have any of the following conditions:
[] Anxiety
[] Cancer
[] Heart Disease
[] Multiple Sclerosis
[] Arthritis
[] Depression
[] High Blood Pressure
[] Osteoporosis
[] Asthma
[] Diabetes
[] High Cholesterol
[] Seizures
[] Blood Disorder
[] Epilepsy
[] Kidney Disease
[] Stroke
SOCIAL HISTORY
Current Marital Status:
[ ] Married [ ] Single [ ] Divorced [ ] Widowed [ ]Partner
Living Status:
[ ] alone [ ] with spouse [ ] with parents [ ] with roommate [ ] assisted living [ ] nursing home
Current Occupation:______________________________
Highest education level: [ ] Grade School [ ] Middle School [ ] High School [ ] College [ ] Post Graduate
Do you use tobacco now or in the past? [ ] Yes, use now [ ] Never used [ ] Previous user
Cigarettes How many per day? _________ How many years? ___________
Cigars
How many per day? _________ How many years? ___________
Do you drink alcoholic beverages? [ ] Never
[ ] Weekly
Have you ever felt the need to cut down on drinking?
Have you ever felt annoyed by criticism of your drinking?
Have you ever felt guilty about your drinking?
Have you ever felt the need for a morning eye-opener?
[ ] 1-2 x week
[
[
[
[
] Yes [
] Yes [
] Yes [
] Yes [
[ ] 3 x week
] No
] No
] No
] No
Have you tried illicit drugs? [ ] Yes, use now [ ] Never used [ ] Previous user
What was the substance?_________________________
FAMILY HISTORY
Please check the box if anyone in your immediate family has had any of the following
for grandparents)
[] Anxiety ____________
[] Arthritis ____________
____________
[] Cancer ____________
[] Depression ____________
[] Heart Disease ____________
[] High Blood Pressure ____________
[] Multiple Sclerosis ____________
[] Osteoporosis ____________
conditions: (NOTE RELATIONSHIP PLEASE Specify maternal/paternal
[] Asthma____________
[]
[] Diabetes ____________
[] High Cholesterol ___________
[] Seizures ____________
[] Epilepsy ____________
[]Kidney Disease ____________
[] Stroke ____________
REVIEW OF SYSTEMS
Please indicate below if you currently have any symptoms/conditions noted below.
Constitutional/General
Fever
Chills
[ ] Yes [ ] No
[ ] Yes [ ] No
Neurologic
Headache
Seizures
[ ] Yes [ ] No
[ ] Yes [ ] No
Ears/Nose/Mouth/Throat
Dizziness
Difficulty Swallowing
[ ] Yes [ ] No
[ ] Yes [ ] No
Cardiovascular
Chest Pain
Irregular Heart beat
[ ] Yes [ ] No
[ ] Yes [ ] No
Endocrine
Diabetes
Fatigue
[ ] Yes [ ] No
[ ] Yes [ ] No
Psychiatric
Depression
Anxiety
[ ] Yes [ ] No
[ ] Yes [ ] No
Gastrointestinal
Ulcers
GERD
[ ] Yes [ ] No
[ ] Yes [ ] No
Genitourinary
Urgent urination
Frequent urination
[ ] Yes [ ] No
[ ] Yes [ ] No
Hematologic/Lymphatic
Anemia
Bleeding Problem
[ ] Yes [ ] No
[ ] Yes [ ] No
Pulmonary
Shortness of Breath
Asthma
[ ] Yes [ ] No
[ ] Yes [ ] No
Blood
Disorder