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MicroSpine Evaluation Form
(This form is for patients scheduled for surgery)
Please read carefully and answer all questions.
Page 1 of 3
1. Name:
Last: ________________________ First: _____________________ MI: _____
2. Age:
______ Height: _________Weight: __________ Male/Female
3. Who referred
you? ______________________________________________________
4. Where do you
live? (city/state)_____________________________________________
5. CC: Describe your pain and
where it is located: ________________________________________________
6. HPI: When did you first
start having pain? _______________________________________________________________________________
7. Circle what
caused your pain: Unknown/ Work accident/ Car accident/ Other accident/ Surgery/
Illness/ Other
8. Had you had
this pain before? Yes/No When?
______________ Please explain:
________________________________________________________________________________ ________________________________________________________________________________
9. If your pain
was caused by an accident, please give the date of the accident and describe the
accident:
_____________________________________________________________________________ _____________________________________________________________________________
10. Circle what
makes your pain worse: Weather/
Physical activity/ Sitting/ Standing/ Walking/ Urination/Bowel movement/ Sneezing/ Coughing/Other
____________________________________________
11. Does the pain
wake you from a sound sleep? Y/N
If so, how often? __________________________
12. Has your pain
become worse recently? Yes/No
When did it get worse?________________________
Explain why you think it became
worse?______________________________________________________________________________
______________________________________________________________________________
13. Do you have
any areas of tingling (pins & needles) Yes/No
Where?________________________________
14. Do you have
any areas of numbness (loss of sensation)? Yes/No
Where? __________________________
15. Do you have
any weakness in your arms, legs hands or feet?
Yes/No Where?
______________________
16. Circle
symptoms, if any: Foot drop/ Foot slaps the floor/ Catch your toe /Drag your
foot/ Other___________________________________________________________________________
17. Circle
symptoms, if any: Shuffle/ Walked stooped/ Loss of walking endurance/ Other
_______________________________________________________________________________
18. Circle treatments you have had for your pain: Physical therapy/ Chiropractic/ TENS unit/ Massage therapy/Acupuncture/ Nerve blocks/ Epidural/Pain clinic / Psychotherapy/ Surgery/ Other _______________________________________________________________________________
19. Do you have
loss of urine when you cough, sneeze or laugh? Yes/No
If so, how long has this been a problem for you?_______________________________________________________________________________
20. Since your pain problem started have you developed loss of bowel or bladder control? Yes/No
How many times has this happened?_______________________________________________
When was the last time this
happened?_____________________________________________
21. Do you have
carpal Tunnel? Yes / No If
so, where? Right
hand / Left hand / Both Hands
22. PAST MEDICAL HISTORY:
Circle any of the following illnesses you have had: Hypertension/ Heart attack,
heart disease/ Emphysema, bronchitis/ Depression/ Epilepsy, seizure/ Diabetes/
Cancer/ Arthritis/ Ulcers/ Stroke/ Hepatitis
If so, please
explain: ______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Print your name here: ___________________________________________
Page 2 of 3
23.
Have you have any other illnesses? Yes/No (explain)_________________________________________
________________________________________________________________________________
24. SURGERY HISTORY: Please
list ALL previous surgeries and the
dates performed:
Date
Type of Surgery
Where
performed
1.______________________________________________________________________________________
2.______________________________________________________________________________________
3.______________________________________________________________________________________
4.______________________________________________________________________________________
5.______________________________________________________________________________________
6.______________________________________________________________________________________
7.______________________________________________________________________________________
8.______________________________________________________________________________________
25. FAMILY HISTORY:
Present
Age or Age at Death
Cause of Death
Medical Illnesses/Problems
Father:
Alive/Deceased
____________________________________________________________________
Mother:
Alive/Deceased
____________________________________________________________________
Brother/Sister:
Alive/Deceased _______________________________________________________________
Brother/Sister: Alive/Deceased
_______________________________________________________________
26. ALLERGIES: List medicines
and types of reactions (nausea, itching, rash, hives, wheezing, palpitations)
Medication
Reaction
1.
________________________________________________________________________________
2._________________________________________________________________________________
3._________________________________________________________________________________
4._________________________________________________________________________________
27. Are you
presently taking COUMADIN, PLAVIX or
any other blood thinners? Yes / No
Please list below.
28. MEDICATIONS: Please List ALL
your medications here.
Medication
Date Started
Dosage Times per
day Purpose of
Medication Prescribing Doctor
1.
______________________________________________________________________________________
2.______________________________________________________________________________________
3.______________________________________________________________________________________
4.______________________________________________________________________________________
5.______________________________________________________________________________________
6.______________________________________________________________________________________
7.______________________________________________________________________________________
8.______________________________________________________________________________________
9.______________________________________________________________________________________
10._____________________________________________________________________________________
29. Have you ever
tried to stop taking your pain medications? Yes/No
30.
What happened when you
stopped?________________________________________________________
31. SOCIAL HISTORY: Circle
your marital status: Married/Single/Divorced/Widowed
32. What is or was
your occupation? _______________________________________________________
33. Circle your
current employment status: Working/
On sick leave/ Disabled/ Retired/ Other______________
Print your name here: ___________________________________________
Page 3 of 3
34. Do you smoke?
Yes/No If so, number of
packs per day? __________ Do
you chew tobacco? Yes/No
35. Do you drink
alcohol? Yes /No Number of
drinks per week: _________
36. Have you ever been treated for alcohol or drug abuse? Yes/No If yes, explain: ________________________________________________________________________________ ________________________________________________________________________________
Circle any of the following medical problems you have had:
Constitutional:
Weight change/ Fever/ Other ________________________________________________
Eyes:
Double vision/ Blurring/ Glasses, contacts/ Other
_______________________________________
Ears,
Nose, Throat & Mouth: Deafness/ Sinusitis/ Hoarseness/ Vertigo/ Other
______________________
Cardiovascular:
Chest pain/ Palpitations/ Other ______________________________________________
Respiratory: Shortness of breath/ Asthma/ Cough/Other
___________________________________________________
Stomach or Bowel: Change in appetite/ Weight change/ Pain/ Diarrhea/ Constipation/ Other ____________________________________________________
Kidney/Bladder/Reproductive: Incontinence/ Pain/ Prostate/ Menstrual/ Other
____________________________________________________
Muscular Skeletal: Fracture/
Sprain/ Arthritis/ Other ___________________________________________
Skin/Breast:
Rash/ Scar/ Lumps/ Other _____________________________________________________
Neurological: Seizures/
Vertigo/ Memory loss/ Headache/ Other _________________________________
Psyche:
Depression/ Hallucinations/ Sleep disturbances/ Other
__________________________________
Endocrine:
Growth/hair changes/ Thirst/ Energy loss/ Other
_____________________________________
Hematological/Immunologic:
Bruising/ Blood clots/ Bleeding/ Other ________________________________
Explanations
(if necessary) ______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
____________________________________________________________________________________
38. Is your injury
workman’s comp related? Yes/No
Automobile insurance related? Yes/No
39. Is there
litigation pending with your injury? Yes/No
If so, who is your lawyer? _________________________
40. Do you want us
to share information with your lawyer if he contacts us? Yes/No
Initials, if yes: ________
Thank you for
completing this questionnaire. At MicroSpine
you will undergo an evaluation to determine the source of your pain
and the treatment options available. Depending
upon our assessment of your problem, our pain management staff, or our surgical
staff, or both, may treat you. We
will make every attempt to fully explain our findings and your options.
Whether you require surgery or pain management services, you should be
aware there are risks involved when undergoing medical procedures.
Possible complications vary from procedure to procedure, but may include
infection, nerve injury, headache, nausea, bleeding, and, very rarely, loss of
life or limb. These complications
are uncommon, but we want you to be an informed patient.
I have read the above and understand,
Print Name:
__________________________________
Signature: __________________________________ Date:
_______________________