Follow Up Form - Spine Medicine
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MR#___________ Name: ______ Spine & Musculoskeletal Medicine _______________ Please Print ______ DOB: Primary Care Physician: Date today:_____ _________ Reason for today’s Visit: __ Treatment as of last visit: Physical Therapy at: Percent of Improvement % or _____No help Injection by Dr. Devney: Percent of Improvement % or _____No help Medication by Dr Devney: Percent of Improvement % or _____No help New Medical Problems: Smoking Status: Non Smoker Current Smoker Former Smoker Pain Location: Neck Right shoulder Left shoulder Right arm Left arm Middle back Lower back Right buttock Left buttock Right leg Left leg Other: ⎕Dull-achy ⎕Dull-achy ⎕Dull-achy ⎕Dull-achy ⎕Dull-achy ⎕Dull-achy ⎕Dull-achy ⎕Dull-achy ⎕Dull-achy ⎕Dull-achy ⎕Dull-achy ⎕Dull-achy ⎕Sharp ⎕Sharp ⎕Sharp ⎕Sharp ⎕Sharp ⎕Sharp ⎕Sharp ⎕Sharp ⎕Sharp ⎕Sharp ⎕Sharp ⎕Sharp ⎕Burning ⎕Burning ⎕Burning ⎕Burning ⎕Burning ⎕Burning ⎕Burning ⎕Burning ⎕Burning ⎕Burning ⎕Burning ⎕Burning ⎕Stabbing ⎕Stabbing ⎕Stabbing ⎕Stabbing ⎕Stabbing ⎕Stabbing ⎕Stabbing ⎕Stabbing ⎕Stabbing ⎕Stabbing ⎕Stabbing ⎕Stabbing ⎕Numb ⎕Numb ⎕Numb ⎕Numb ⎕Numb ⎕Numb ⎕Numb ⎕Numb ⎕Numb ⎕Numb ⎕Numb ⎕Numb ⎕Deep ache ⎕Deep ache ⎕Deep ache ⎕Deep ache ⎕Deep ache ⎕Deep ache ⎕Deep ache ⎕Deep ache ⎕Deep ache ⎕Deep ache ⎕Deep ache ⎕Deep ache ⎕Pins and needles ⎕Pins and needles ⎕Pins and needles ⎕Pins and needles ⎕Pins and needles ⎕Pins and needles ⎕Pins and needles ⎕Pins and needles ⎕Pins and needles ⎕Pins and needles ⎕Pins and needles ⎕Pins and needles Rate your pain (0 = no pain to 10 = worst you can imagine) Pain today-right now: 0 Pain at its worst: 0 Pain at its best: 0 How often do you have pain? ⎕ Intermittently 1 1 1 2 2 2 3 3 3 ⎕ Constantly 4 4 4 5 5 5 ⎕ Daily 6 6 6 7 7 7 8 8 8 9 9 9 10 10 10 ⎕Other:________ _______ What makes pain BETTER:__________________________________________________________________________ What makes pain WORSE:___________________________________________________________________________ Are you experiencing any of the following: (Check all that apply) No other complaints ___Fever ___Weight loss ___Painful swallowing ___Chest pain ___Shortness of breath ___Dizziness ___Abdominal pain ___Vomiting or nausea ___Heartburn ___Constipation ___Diarrhea ___Bloody stool ___Urinary frequency ___Urine infection ___Anemia ___Difficulty with balance ___Walk with a limp ___Dragging foot ___Seizure disorder ___Paralysis ___Stress ___Depression ___Sleep disturbance ___Rash Current Medication:____________________________________________________ _____________________________ __________________________________________________________________________________________________ New Medications since last office visit:___________________________________________________________ ______ The above information is true to the best of my knowledge:__________________________________________________
