Back and Neck Doctors
807 South Parson's Avenue Brandon, FL 33511
Dr. George DelVillar
Dr. Kenneth A. Wetherington
Dr. Ryan Humphrey
To help us understand your problems, please complete ALL QUESTIONS on ALL of the attached forms.
Name ___________________________________ Age _____ Date of Birth ____________ Date ____________
Height ______ Weight ______ Eye Color ________ Tattoos/site ______________ Scars/site _________________
Who referred you to our office?_____________________________________________________________________
Family/Primary Care Physician ____________________________________
Phone (
)____________________
Which part of your body hurts the most? ______________________________________________________________
How long have you had this pain? _________days, weeks, months, years
Was pain caused by a Car Accident/Trauma? Yes
No
Illness? Yes
No
Unknown Cause? Yes
No
If Car Accident/ Trauma please explain and give dates ___________________________________________________
Are you involved in any litigation or law suit as a result of your pain?
Are you seeking Worker’s Compensation as a result of your pain?
Yes
Yes
No
No
On a scale of 0-10, “0” being no pain and “10” being unbearable pain, circle the number that describes your level of pain:
No Pain=0
1
2
3
4
5
6
7
8
9
10=Unbearable Pain
Shade ALL the areas where you have pain:
Circle ALL the words that describe your pain:
Dull
Aching
Shooting
Sharp
Stabbing
Burning
Circle the word that describes how OFTEN you have pain:
Constant (100% of time)
Frequent (75%)
Tingling
Deep
Radiating
Numbness
Intermittent (50%)
Tightness
Excruciating
Occasional (25%)
Patient Name __________________________________________________
Date _________________
Please indicate the factors or activities of daily living that increase or decrease your pain:
Factors
Increase Decrease No Effect
Factors
Increase Decrease No Effect
Bending
Weather Change
Lifting
Work
Sitting
Sexual Activity
Standing
Social Life
Walking
Exercise
Sleeping
Travel
Vacuum/Mopping
Reading
Bath/Dressing
Lying Down
Driving
Bowel Movement
Sneeze/Cough
Bright Lights
Hot Packs
Ice Packs
Circle any of the following Symptoms that you have?
Neck Pain
Back Pain
Do you have Headaches?
Neuropathy/Nerve Pain
Yes
Numbness/Tingling
How long do they last? ______Minutes
Tobacco
What symptoms do you get?
What relieves the pain?
Bowell/Bladder Incontinence
No
Where are they located?__________________________________
Circle what triggers them?
Weakness
______Hours
Alcohol
Nausea/vomit
Quiet room
What type of pain?________________________________
______Days
Exercise
Noise
______Weeks
Sex
Photophobia/phonophobia
Dark Room
Pain Meds
Weather
______Months
Menstrual Cycle
Myosis/Ptosis
______Years
Other_____________
Lacrimal/Nasal Congestion
Other_________________________
Please list any physicians you have seen for your pain:
Name
Specialty
Recommendations
___________________________
_________________________
______________________________________________
___________________________
_________________________
______________________________________________
Please check any of the following treatments you have received for this pain problem
Nerve Blocks
Date & Details___________________________________________
Improved? Yes No
Physical Therapy
Date & Details___________________________________________
Improved? Yes No
Chiropractic
Date & Details___________________________________________
Improved? Yes No
Psychiatrist/Psychologist
Date & Details___________________________________________
Improved? Yes No
Surgery
Date & Details___________________________________________
Improved? Yes No
Other
Date & Details___________________________________________
Improved? Yes No
Patient Name __________________________________________________
Date _________________
Circle which diagnostic test you have had and what were the results
X-Rays
Body Part?__________________
Result____________________________________
Date____________
MRI Scan
Body Part?__________________
Result____________________________________
Date____________
CT Scan
Body Part?__________________
Result____________________________________
Date____________
EMG/NCV
Body Part?__________________
Result____________________________________
Date____________
Bone Scan
Body Part?__________________
Result____________________________________
Date____________
Other
Body Part?__________________
Result____________________________________
Date____________
Please Circle Past or Current Medical Problems:
Heart Disease
Lung Disease
Diabetes
Stroke
Herpes (Shingles)
Hypertension
Kidney Problems
Liver Disease
Seizures
Open Wounds
Migraines
Thyroid Disease
GERD/Ulcer
Infection
Depression/Anxiety
Other____________________________________
Have you ever been diagnosed with cancer?
Are you currently receiving treatment?
Yes
Yes
No
No
If yes, what type and explain? ________________________________
If yes, what types of treatment(s)?__________________________________
Please list ALL medication you are currently taking:
1)_______________________
4)_______________________ 7)_______________________ 10)______________________
2)_______________________
5)_______________________ 8)_______________________ 11)______________________
3)_______________________
6)_______________________ 9)_______________________ 12)______________________
Are you taking Narcotics from any physician?
Yes
Do you have any allergies to medication or food?
Medication
No
Yes
No
Reaction
Medication
Reaction
1)___________________ _______________________
4)__________________ ________________________
2)___________________ _______________________
5)__________________ ________________________
3)___________________ _______________________
6)__________________ ________________________
Have you ever taken any Blood Thinners, Anticoagulants, Coumadin, Plavix, Pletal? Yes No
Have you ever taken any cortisone or steroids?
Yes
No
Any reaction?____________
Any reaction?___________________
Please list any Surgeries and the date they were done:
Surgery______________________ Date_______________
Surgery______________________ Date_______________
Surgery______________________ Date_______________
Surgery______________________ Date_______________
Patient Name __________________________________________________
Date _________________
Review of Systems:
Please CIRCLE if you have or ever had any of the following:
Cardiovascular
Respiratory
Genitourinary
Muscle/Joint
Neurology
Palpatation
Chronic Cough
Change in Bowel Control
Redness in Joints
Epilepsy /Seizures
Leg Swelling
Wheezing
Change in Bladder Control
Arthritis/Joint Disease
Weakness
Chest Pain Produce Sputum
Blood in Urine
Frequent spasm
Dizzy/Fainting
Hypertension
Painful Urination
Back/Neck Problems
Numbness
CPOD/Asthma
Shortness of Breath
Psychiatric
Constitutional
Depression
Recent Weight Loss
Have you been treated for HIV virus? ___ Yes
Anxiety
Recent Weight Gain
Date ____________
Stress
Fever/Chills
Have you been diagnosed with any of the following?
Prev. Psych. Care
Visual Change
Hepatitis
Other
Hearing Change
Any sexually transmitted disease?
___ Positive
___ Yes
___ No
___ Negative
___ No
___Yes
___No
Sleep Abnormalities
Other
Social History:
Do you currently work?
Marital Status:
___ Yes
___ Married
___No
What is/was your occupation? _________________________
___ Divorced
___ Single
___ Widowed
Number of children______
Education _________________________________________
Dominate Hand: ___ Right
___ Left
Do you use any of the following?
___Methamphetamine
Is there any possibility that you are pregnant? ___ Yes
___Cigarettes
___Heroin
___Alcohol
___Club Drugs
___Cocaine
___Prescription Drugs
___Marijuana
___Other
If Yes, the last time used: ________________________________
Family History:
Describe current health, age, cause of death, illness, diabetes, hypertension, etc
Living
Age
Yes
No
Medical History or Cause of Death
Father____________________________________________________________________________________
Mother____________________________________________________________________________________
Brother____________________________________________________________________________________
Sister______________________________________________________________________________________
Other______________________________________________________________________________________
Other______________________________________________________________________________________
___ No
Patient Name __________________________________________________
Date _________________