MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
Please print legibly in black ink. Answer only questions applicable to your condition.
Leave other spaces blank. This form will become part of your medical record.
Date you are filling out this form:
PART I
PERSONAL DATA
Name:
Last
First
Middle
Medical Record #:
Referring Physician:
Referring Facility:
Age:
00324-001 (REV. 4-08)
■ Male ■ Female
Height:
Weight:
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Page 1 of 12
MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
PART II
PAIN DIAGRAM
Please note the orientation of the diagrams below and mark on them the exact spots where you are
experiencing any of the following sensations on your own body (please use only the symbols listed):
= = = = = Numbness
x x x x x x Pain
••••••• Other, explain
FRONT
RIGHT
BACK
LEFT
LEFT
RIGHT
Circle the number on each line below indicating the level of your pain.
What was your LEAST pain over the past 1–2 weeks?
(NONE) 0 1 2 3 4 5 6 7 8 9 10 (SEVERE)
What was your WORST pain over the past 1–2 weeks?
(NONE) 0 1 2 3 4 5 6 7 8 9 10 (SEVERE)
What is your pain like today?
(NONE) 0 1 2 3 4 5 6 7 8 9 10 (SEVERE)
00324-001 (REV. 4-08)
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MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
PART II continued
Which condition best describes the percentage of pain in your back vs. in your legs:
■ 100% back / 0% legs
■ 75% back / 25% legs
■ 50% back / 50% legs
■ 25% back / 75% legs
■ 0% back / 100% legs
Please further define your BACK PAIN (not leg pain) (check all that apply):
■ Intermittent
■ Central
■ Dull
■ Nuisance
■ Bearable
■ Manageable
■ Waxes/Wanes
■ Right sided
■ Aching
■ Nagging
■ Unbearable
■ Unmanageable
■ Constant
■ Left sided
■ Sharp
■ Throbbing
■ Excruciating
■ Terrible
Please further define your LEG PAIN:
My leg pain is
% right sided
% left sided
(These two should add up to a total of a 100%.)
Aggravating factors
Does coughing, sneezing, or bearing down to have a bowel movement make your back or leg pain pain worse?
■ Yes
■ No
What other position or activity causes your pain to increase?
What time of day is your pain at its worst? (check one)
■ Morning
■ Late afternoon
■ Early afternoon ■ Night
Which of the following make your pain worse? (check one)
■ Walking
■ Standing
■ Sitting
■ Lying down
What do you do to relieve the pain?
00324-001 (REV. 4-08)
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MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
PART II continued
ASSOCIATED SYMPTOMS
Before we move on to describe the history of your pain, we have some questions directed at helping us to
know whether your spinal nerves are being compressed and affecting other basic functions.
Do you have numbness in the following areas? (check all that apply):
■ Buttocks
■ Perianal
■ Back of upper thigh
■ Vaginal
■ Penile
■ Scrotal
We also would like to get a sense of your overall health and well-being:
Do you feel generally well?
How is your appetite?
■ Yes
■ Good
■ No
■ Bad
Circle a number below on each line to indicate any problems you are experiencing with:
NONE
SEVERE
Anxiety
1
2
3
4
5
6
7
8
9
10
Depression
1
2
3
4
5
6
7
8
9
10
Poor sleep
1
2
3
4
5
6
7
8
9
10
Irritability
1
2
3
4
5
6
7
8
9
10
Part III (A)
History of your low back and leg pain
Now we need to know more about the history of your low back and leg pain, as well as treatment that has
been rendered in the past.
Approximately when did you begin having problems with your low back and/or leg pain?
month
/
year
Can you attribute your pain to any specific cause?
■ No ■ Yes If yes, please describe:
■ Gradually
■ Suddenly
■ Woke up with it
■ Fall: (how high
ft.)
■ Twisting
■ Bending
■ Running
■ Pushing
■ Lifting: (how much
lbs.)
■ Pulling
■ Reaching
■ Direct blow
■ Motor vehicle accident■ Other:
How did it begin (check all that apply):
00324-001 (REV. 4-08)
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Page 4 of 12
MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
Part III (A) continued
History of your low back and leg pain
■ Work
■ School
Is there/will there be legal action? ■ No ■ Yes
■ Sports
Was this the result of an injury at:
■ Unrelated
What is the current status of this action?
■ No ■ Yes
Have you or will you hire a personal attorney? ■ No ■ Yes ■ Undecided
Is there a Workers’ Compensation claim pending/active?
Did you ever have to be hospitalized for your back/neck pain (other than for surgery)?
Have you had spinal surgery?
■ No ■ Yes If yes, please describe below:
How many spine surgeries have you had?
1.
■ No ■ Yes
Please list the three most recent spine surgeries:
datesurgeon location
Type of procedure:
2.
datesurgeon location
Type of procedure:
3.
datesurgeon location
Type of procedure:
Over the last two months is your pain getting:
■ Better
■ Worse
■ Same
By how much: (circle one) 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
If your pain is worsening, how are you gauging that it is actually worsening? Please describe:
Who are the main doctors that are taking care of your back?
Physician
Location
1.
2.
3.
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MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
Part III (B)
Now we would like to know what type of treatment has been attempted over the last year:
A. Physical Therapy:
Over the last year, have you tried physical therapy? ■ Yes ■ No
What did the therapy include? (please list):
1.
2.
3.
Approximately how many therapy visits did you have?
Do you continue with therapy or exercises at home?
Overall, did you find therapy helpful?
Are you doing any other aerobic exercise on a regular basis?
■ Yes
■ Yes
■ Yes
■ No
■ No
■ No
B. Have you tried lumbar epidural steroid injections? (These are usually done by an anesthesiologist,
sometimes under X-ray guidance, placing steroids into the spinal canal.)
■ Yes
■ No
If yes, how many have been done over the last year?
When was the last one done?
/
MonthYear
■ Yes
Overall, do you find the epidural steroid injections helpful?
If they are helpful to you, how long does the benefit last?
days
weeks
■ No
months
C. Over the last year, have you tried a lumbar brace or corset?
Did you find it helpful?
Do you continue to use it?
■ Yes
■ Yes
■ Yes
■ No
■ No
■ No
D. Over the last year, have you tried a tens unit?
Did you find it helpful?
Do you continue to use it?
■ Yes
■ Yes
■ Yes
■ No
■ No
■ No
E. Over the last year, have you tried a cane or walker?
Did you find it helpful?
Do you continue to use it?
■ Yes
■ Yes
■ Yes
■ No
■ No
■ No
F. Over the last year, have you sought the care of a chiropractor?
Did you find it helpful?
Do you continue to use it?
■ Yes
■ Yes
■ Yes
■ No
■ No
■ No
G. Over the last year, have you tried acupuncture?
Did you find it helpful?
Do you continue to use it?
■ Yes
■ Yes
■ Yes
■ No
■ No
■ No
H. Over the last year, have you tried weight loss?
Were you able to lose weight?
How many pounds?
■ Yes
■ Yes
■ No
■ No
00324-001 (REV. 4-08)
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Page 6 of 12
MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
Part III (C)
Limitations
Despite the treatments tried and medications being used, are you still limited by your
back and/or leg pain?
■ Yes ■ No
List recreational activities you cannot do because of your back and/or leg pain.
1.
2.
3.
4.
What social activities have you given up because of the pain?
Basic Functional Limitations
How far can you comfortably walk?
blocks
How far could you walk 2 years ago?
Does walking bring on, or make worse, the pain in your
After what period of time:
minutes
blocks
■ legs ■ low-back?
hours
What limits you at that point?
How long after you stop walking does it take before the pain subsides?
seconds
minutes
hours
After walking and inducing pain, what do you do to relieve it?
How long can you comfortably stand?
minutes
What limits you at that time?
How long can you comfortably sit?
minutes
What limits you at that time?
00324-001 (REV. 4-08)
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Page 7 of 12
MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
Part III (C) continued
Work History and limitations
■ Yes
Are you currently working?
■ No
If yes, how many days per month do you miss from work because of your pain:
If no, did you stop working because of your pain?
■ Yes
days.
■ No
Current/Recent Employer:
Date of Hire:
Usual occupation:
Briefly describe your job:
Do/did you like your job?
■ Very satisfied
■ Satisfied
■ Dissatisfied
■ Hate it
Physical demands of your job:
■ Very heavy (frequently lift > 100 lbs.)
■ Heavy (frequently lift > 60 lbs.)
■ Moderate (frequently lift > 30 lbs.)
■ Light (frequently lift 15–30 lbs.)
■ I use my hands to do repetitive motion type tasks
■ Sedentary (no lifting or repetitive motion task)
Work status today:
■ Regular duties
■ Light or modified duties (date began)
■ On disability (date began)
■ On time loss (date began)
What are your limitations at work? Cite specific duties or activities with which you have difficulty.
PART IV
PAST SURGICAL HISTORY
You’ve already listed your spinal surgeries. Other than spine surgery, please list your last five surgeries:
Date
Procedure
1.
2.
3.
4.
5.
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MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
PART V
SOCIAL HISTORY AND HABITS
1. Work status:
■ Homemaker ■ Working ■ Retired ■ Disabled ■ On leave
2. Occupation (current or most recent):
3. Date last worked:
4. If not currently working, reason stopped:
5. Marital status:
■ single ■ married ■ divorced ■ widowed ■ cohabiting
6. Number of children:
7. I live:
■ alone ■ with:
8. Tobacco use:
■ never ■ cigar ■ chew ■ pipe
■ cigarettes
■ quit (when)
packs/day for
years (total)
9. Alcohol:
■ never or rare ■ social ■ frequently drunk (more than twice a week)
■ alcoholic ■ recovering alcoholic, number of years sober
10. Drug use:
■ never
■ in the past ■ current ■ IV drugs
REVIEW OF MEDICAL PROBLEMS
Check all that apply: ■ None apply
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
Reading glasses
Change of vision
Loss of hearing
Ear Pain
Hoarseness
Nosebleeds
Difficulty swallowing
Morning cough
Shortness of breath
Fever or chills
Heart or chest pain
Abnormal heartbeat
Swollen ankles
Calf cramps w/ walking
Poor appetite
Toothache
Gum trouble
Nausea or vomiting
Stomach pain
Ulcers
Frequent belching
00324-001 (REV. 4-08)
■
■
■
■
■
■
■
■
■
■
■
■
■
■
Frequent diarrhea
Frequent constipation
Hemorrhoids
Frequent urination
Burning on urination
Difficulty starting urination
Get out more than once
every night to urinate
Frequent headaches
Blackouts
Seizures
Frequent rash
Hot or cold spells
Recent weight change
Nervous exhaustion
Women Only:
■ Irregular periods
■ Vaginal discharge
■ Frequent spotting
Other:
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MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
PART V continued
REVIEW OF MEDICAL PROBLEMS continued
Is your primary care physician aware of the above checked problems?
■ Yes
■ No
Do you have any other medical problems that have not already been listed? For example, consider
problems with heart, lungs, kidney, thyroid, pancreas, adrenal gland, diabetes, stomach ulcers, gastritis, arthritis,
anemia, bone marrow, infections (tuberculosis, bladder infections, etc.), epilepsy, stroke, or other.
I acknowledge that I compleded this form and agree to its content.
Date:
Signature:
00324-001 (REV. 4-08)
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Page 10 of 12
MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
SCORE
PART VI
OSWESTRY DISABILITY INDEX
This questionnaire has been designed to give us information as to how your back (or leg) trouble has affected
your ability to manage in everyday life. Please answer every section. Mark only ONE box in each section
that most closely describes you today.
Section 1—Pain Intensity:
I have no pain at the moment.
The pain is very mild at the moment.
The pain is moderate at the moment.
The pain is fairly severe at the moment.
The pain is very severe at the moment.
The pain is the worst imaginable at the moment.
Section 2—Personal Care (washing, dressing, etc.):
I can look after myself normally w/o causing
extra pain.
I can look after myself normally, but it is very painful.
It is painful to look after myself. I am slow and careful.
I need some help but manage most of my
personal care.
I need help every day in most aspects of self-care.
I don’t get dressed, wash with difficulty, and
stay in bed.
Section 3—Lifting:
I can lift heavy weights without extra pain.
I can lift heavy weights, but it gives me extra pain.
Pain prevents me from lifting heavy weights off
the floor, but I can manage if they are conveniently
positioned, e.g., on a table.
Pain prevents me from lifting heavy weights,
but I can manage light to medium weights if they
are conveniently positioned.
I can lift very light weights.
I cannot lift or carry anything at all.
Section 4—Walking:
Pain does not prevent me from walking any distance.
Pain prevents me from walking more than one mile.
Pain prevents me from walking more than a
quarter of a mile.
Pain prevents me from walking more than 100 yards.
I can only walk while using a stick or crutches.
I am in bed most of the time and have to crawl
to the toilet.
Section 5—Sitting:
I can sit in any chair for as long as I like.
I can sit in my favorite chair as long as I like.
Pain prevents me from sitting for more than 1 hour.
Pain prevents me from sitting for more than a 1⁄2 hour.
Pain prevents me from sitting for more than 10 mins.
Pain prevents me from sitting at all.
00324-001 (REV. 4-08)
Section 6 — Standing:
I can stand as long as I want without extra pain.
I can stand as long as I want, but it gives me
extra pain.
Pain prevents me from standing for more than 1 hour.
Pain prevents me from standing for more than
a 1⁄2 hour.
Pain prevents me from standing for more than
10 minutes.
Pain prevents me from standing at all.
Section 7— Sleeping:
My sleep is never disturbed by pain.
My sleep is occasionally disturbed by pain.
Because of pain, I have less than 6 hours sleep.
Because of pain, I have less than 4 hours sleep.
Because of pain, I have less than 2 hours sleep.
Pain prevents me from sleeping at all.
Section 8 — Sex life (if applicable):
My sex life is normal and causes no extra pain.
My sex life is normal, but causes some extra pain.
My sex life is nearly normal but is very painful.
My sex life is severely restricted by pain.
My sex life is nearly absent because of pain.
Pain prevents any sex life at all.
Section 9 — Social Life:
My social life is normal and causes me no extra pain.
My social life is normal, but increases the degree
of pain.
Pain has no significant effect on my social life
apart from limiting my more energetic interests,
e.g., dancing, sports, etc.
Pain has restricted my social life and I do not
go out as often.
Pain has restricted my social life to my home.
I have no social life because of pain.
Section 10 —Traveling:
I can travel anywhere without extra pain.
I can travel anywhere, but it gives me extra pain.
Pain is bad, but I manage journeys over 2 hours.
Pain restricts me to journeys of less than 1 hour.
Pain restricts me to short necessary journeys
less than 30 minutes.
Pain prevents me from traveling except to
receive treatment.
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MR#:
Name:
Regional Spinal Surgery
Date:
Low Back/Leg Pain
Intake Questionnaire
MD:
SCORE
PART VII
VISUAL ANALOGUE SCALE FOR PAIN
PATIENT INSTRUCTION
Please put one vertical mark on the horizontal line below to show how bad your pain is today.
A mark closer to ‘No Pain’ means less pain than a mark closer to ‘Worst Pain Imaginable’.
Worst Pain
Imaginable
No Pain
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