Conservative Spine and Joint Center
Ruben Diaz, M.D.
___________
Today’s Date
Patient Name:_____________________________________________________ DOB: _____________________
Address:_____________________________________________________________________________________
City: _________________________________ State: ________ Zip: ___________ ss # _____________________
Phone: ___________________ Alternate Phone: ________________Email:_____________________________
Height _____ Weight _____
� Male � Female
Marital Status ____________________
Emergency Contact Name: ___________________________ Relationship: _____________________
Phone: ______________________________________________________________________________
Referring Physician: __________________________________ Phone: _________________________
Primary Physician: ___________________________________ Phone: __________________________
Do you want your medical records sent to any of the physicians mentioned above? Y � N �
Is this pain/problem a work related injury? Y � N � Do you have an active Worker’s Comp case? Y � N �
Is this pain/problem related to an auto accident? Y � N �
Do you have any legal action pending related to this pain/problem or any other health problem? Y � N �
if yes to any of the above, do you have an attorney? Y � N �
Attorney’s name:_________________________________ Phone: ____________________________________
Primary Insurance: _________________________ Policy # ________________Group # ____________
Claims Address: _______________________________________________________________________
Policy Holder: _______________________________ Relation to patient: _______________________
Policy Holder ss # _________________________ Policy Holder DOB: ___________________________
Secondary Insurance: _______________________ Policy # ________________Group # ___________
Claims Address: _______________________________________________________________________
Policy Holder: _______________________________ Relation to patient: _______________________
Policy Holder ss # _________________________ Policy Holder DOB: ___________________________
I hereby authorize my physician to release any information regarding my medical condition,
including disability or employment related information concerning my claims to insurance
carrier(s), authorized agent(s), or attorney(s) for the purpose of validating and delineating
benefits payable in connection with my incurred medical expenses. I understand that I or my
authorized representative may receive a copy of this authorization upon request. I also
authorize direct payment of benefits to my physician. I understand I am responsible for all
charges whether or not covered by insurance.
SIGNATURE: __________________________________ Date: ___________________________
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Patient Name:_________________________
PRESENT COMPLAINT:
Date of injury/Accident/Onset of problem: _________________________
Describe in your own words the pain/problem(s) you would like help with: __________________________
_____________________________________________________________________________________________
Where is your problem located? � Neck � Upper Back � Lower Back � Arm (rt/lft) �Hip �Leg(rt/lft)
Circle Pain level TODAY: 0=none 10=worst
0 1 2 3 4 5 6 7 8 9 10
Is the pain? (Circle all that apply): Sharp
Dull
Stabbing
Aching
Burning
Stiffness
Throbbing “Electrical” shooting pain Tingling
Pins & needles sensations
Is the pain? (Circle one):
Constant
comes & goes
Mention all things that make the pain better: ____________________________________________________
Mention all things that make the pain worst: ____________________________________________________
Have you had any previous treatments (i.e. medications, therapy, injections, surgery) for this
pain/problem? If yes, list them all here___________________________________________________________
_____________________________________________________________________________________________
Tests you have had: (circle all that apply): x-ray
CT Scan
MRI
EMG/NCS
DEXA
Myelogram
Discogram
Other:_________________
Pain Drawing: (Please mark these drawings according to area(s) that hurt):
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RIGHT
LEFT
RIGHT
Patient Name:_________________________
OCCUPATIONAL HISTORY:
Current work status: �Working full time
�Student
�Working restricted duty (since ________)
�Disabled
�Homemaker
�Unemployed
�Retired
Occupation:_______________________________ Employer: _________________________________
Have you missed any time for work due to this pain/problem? Y � N � When? ___________________
Have you had neck pain/arm numbness/arm weakness before this episode? Y � N � When? ____________
Have you had back pain/leg numbness/leg weakness before this episode? Y � N � When? ______________
PAST MEDICAL HISTORY: (Please check below if you have, or have had, any of these medical condition)s:
� NO PAST MEDICAL PROBLEMS
� Acid reflux
� Adverse reaction to anesthesia
Type of Reaction:____________
� Alzheimer’s or significant memory loss
� Anemia
� Angina or chest pain
� Asthma
�
�
�
�
�
�
�
�
Coronary artery disease
Dental disease
Depression
Diabetes
Emphysema
Epilepsy/Seizures
Fibromyalgia
Gout
�
�
�
�
�
�
�
�
Kidney disease
Osteoarthritis
Osteoporosis
Pneumonia
Psychiatric disorder
Rheumatoid arthritis
Sickle cell
Sleep apnea
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�
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Artrial fibrillation or erratic heartbeat
Bladder problems
Bleeding ulcers
Blood clot
� Legs � Lungs
� Cancer Type:_________________
� Congestive heart failure
�
�
�
�
�
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Hemophilia/Excessive bleeding
� CPAP machine
Hepatitis
� Stroke (CVA)
High blood pressure/Hypertension � Thyroid disease
High cholesterol
� Other not listed, explain:
HIV or AIDS
_______________________
Infections:_______________
_______________________
MRSA? � Yes � No
SURGICAL HISTORY: (Please check below if you have had any of these surgeries):
� NO PREVIOUS SURGERY
� Abdominal surgery
Type of surgery:_________
� Aneurysm
� Angioplasty/Stents
� Artery bypass of arm or leg
� Bone /Joint surgery
Type of surgery:___________
�Carotid surgery
� Spine Surgery (circle one)
cervical, thoracic, lumbar
Date: _______________
� Cervical spine surgery
� Colon surgery
� Coronary bypass (CABG)
� Gastric bypass surgery
� Heart valve replacement
�
�
�
�
�
Hysterectomy
Lumbar spine surgery
Pacemaker/Defibrillator
Prostate surgery
Breast surgery
Type of surgery:________
�Other not listed, explain:
______________________
FAMILY HISTORY: (Please check below if any of your immediate relatives have had any of the following):
�
�
�
�
�
�
NO FAMILY MEDICAL HISTORY TO REPORT
Adopted � Yes � No
� Cancer
Adverse reaction to anesthesia
� Osteoarthritis
Depression
� Bleeding disorders
Heart disease
� Stroke
Blood clots/Pulmonary embolism
� Other not listed, explain:
� Hypertension
� Diabetes
� Osteoporosis
� Rheumatoid arthritis
________________________
Patient Name:_________________________
SOCIAL HISTORY:
Marital Status:
� Single � Married
� Partner
� Divorced
� Widow/Widower
Hobbies _____________________________________________________________________________________
Smoking: � Never smoked � Former smoker
� Current smoker
How many packs/day? ___________
Do you dip or chew tobacco? Y � N � If Yes, how much per day? ____________________________________
Do you drink alcoholic beverages? Y � N � If Yes, how many drinks per week? _________________________
Have you ever had a problem with drug dependence or illicit drug use? Y � N � If Yes, please explain:
_____________________________________________________________________________________________
REVIEW OF SYSTEMS: (Please circle below if you have any of these symptoms- also, give a brief description.):
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8.
Constitutional: fever, recent weight gain/loss, appetite problems __________________________________
Eyes: double vision, blurring, difficulty seeing ___________________________________________________
Ears, Nose, Mouth, Throat: deafness, sinusitis, hoarseness, dizziness _______________________________
Cardiovascular: chest pain, palpitations, murmur, extra beats _____________________________________
Respiratory: shortness of breath, wheezing, cough, bloody cough __________________________________
Gastrointestinal: abdominal pain, constipation, diarrhea, rectal bleeding ___________________________
Urologic: pain with urinating, hesitant urination, bleeding, incontinence ____________________________
Gynecologic: breast masses, pain, discharge_____________________________________________________
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*Are you sexually active? Y � N � *Birth control used: __________ *Any chance you could be pregnant? Y � N
9. Skin: persistent rashes or lesions, changes in moles ______________________________________________
10. Neurologic: seizures, loss of balance/coordination, weakness, memory loss_________________________
11. Psychiatric: depression, anxiety, hallucinations, sleep disturbances _______________________________
12. Endocrine: excessive thirst, excessive urination, heat/cold intolerance ____________________________
13. Blood & Lymphatic: anemia, bleeding tendencies, swollen nodes _________________________________
14. Allergic and Immunologic: hives, eczema, persistent itching _____________________________________
15. Musculoskeletal: stiffness, joint pain/deformity, muscle wasting, spine pain radiating to arms or legs
numbness/tingling _____________________________________________________________________________
16. Other problems not covered above: _______________________________________________________________
CURRENT MEDICATIONS
DOSE
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ALLERGIES
REACTION
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Are you allergic to latex? � Yes � No If so what is the allergy?__________________________________
Patient signature: ___________________________________
Date: _____________
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