NAME:_____________________________________________________

DATE:__________________

BIRTHDATE:__________________

HEIGHT:_____ft.

_____in.

WEIGHT:___________lbs.

Referring doctor’s name & address:	_____________________________________________________ _____________________________________________________
Internist or family doctor’s name & address:	________________________________________ Same as above _____________________________________________________

A.	Chief Complaint
	1.	What is your MAIN reason for seeing the doctor? (Check all that apply)
		___Neck Pain	Arm, shoulder, or hand:	___Pain	___Numbness	___Weakness
		___Back Pain	Leg, buttock, or foot:	___Pain	___Numbness	___Weakness
	2.	How long have you had this problem? __________________________________________________
	3.	Has this problem recently gotten worse? YES / NO If YES When? ____________________________
	4.	What started the problem? ___________________________________________________________

B. Pain and Numbness Diagrams

Mark where you have PAIN	Mark where you have NUMBNESS or TINGLING

Right Left Left Right	Right Left Left Right

My pain level is (circle one):	0	1	2	3	4	5	6	7	8	9	10
	None		Slight		Moderate		Severe		Extreme		Could not be worse

C.	Complete this section for NECK/ARM problems ONLY.
	1.	What portion of your pain is in your NECK versus your ARM(s)? (Check only one)
		___No neck or arm pain	___NECK and ARM pain are about equal (50/50)
		___All NECK pain, no arm pain	___Mostly ARM pain, only some neck pain
		___Mostly NECK pain, some arm pain	___All ARM pain, no neck pain

2.	What portion of your ARM PAIN is on the RIGHT versus the LEFT? (Check only one)
	___No arm pain	___RIGHT and LEFT arms are about equal (50/50)
	___RIGHT arm pain, no left arm pain	___Mostly LEFT arm pain, some right arm pain
	___Mostly RIGHT arm pain, some left arm pain	___LEFT arm pain, no right arm pain

If you have ARM PAIN, where do you feel it? (Check all that apply)

RIGHT:

___Shoulder

___Arm

___Forearm

FINGERS:

___Thumb

___Index

___Long

___Ring

___Small

LEFT:

___Shoulder

___Arm

___Forearm

FINGERS:

___Thumb

___Index

___Long

___Ring

___Small

If you have ARM NUMBNESS, where do you feel it? (Check all that apply)

RIGHT:

___Shoulder

___Arm

___Forearm

FINGERS:

___Thumb

___Index

___Long

___Ring

___Small

LEFT:

___Shoulder

___Arm

___Forearm

FINGERS:

___Thumb

___Index

___Long

___Ring

___Small

If you have ARM WEAKNESS, where do you feel it? (Check all that apply)

RIGHT:

___Shoulder

___Arm

___Forearm

FINGERS:

___Thumb

___Index

___Long

___Ring

___Small

LEFT:

___Shoulder

___Arm

___Forearm

FINGERS:

___Thumb

___Index

___Long

___Ring

___Small

Are you right- or left-handed? (Circle one) RIGHT LEFT

	7.	Please indicate which, if any, of these problems you are experiencing. (Check all that apply)
		___Pain or numbness that is worse at night than during the day
		___Pain or numbness that is worse with overhead activity (e.g, washing or drying hair)
		___Difficulty picking up small objects (e.g, keys, coins) or buttoning shirts
		___New difficulty with handwriting or penmanship
		___Problems with balance or frequent tripping
		___Headaches in the back of the head

D.	Complete this section for BACK/LEG problems ONLY.
	1.	What portion of your pain is in your BACK versus your LEG(s)? (Check only one)
		___No back or leg pain	___BACK and LEG pain are about equal (50/50)
		___All BACK pain, no leg pain	___Mostly LEG pain, only some back pain
		___Mostly BACK pain, some leg pain	___All LEG pain, no back pain

2.	What portion of your LEG PAIN is on the RIGHT versus the LEFT? (Check only one)
	___No leg pain	___RIGHT and LEFT legs are about equal (50/50)
	___RIGHT leg pain, no left leg pain	___Mostly LEFT leg pain, some right leg pain
	___Mostly RIGHT leg pain, some left leg pain	___LEFT leg pain, no right leg pain

If you have LEG PAIN, where do you feel it? (Check all that apply)

RIGHT:

___Buttock

___Groin

___Front of thigh

___Side of thigh

___Back of thigh

___Calf

___Foot

LEFT:

___Buttock

___Groin

___Front of thigh

___Side of thigh

___Back of thigh

___Calf

___Foot

If you have LEG NUMBNESS, where do you feel it? (Check all that apply)

RIGHT:

___Buttock

___Groin

___Front of thigh

___Side of thigh

___Back of thigh

___Calf

___Foot

LEFT:

___Buttock

___Groin

___Front of thigh

___Side of thigh

___Back of thigh

___Calf

___Foot

If you have LEG WEAKNESS, where do you feel it? (Check all that apply)

RIGHT:

___Buttock

___Groin

___Front of thigh

___Side of thigh

___Back of thigh

___Calf

___Foot

LEFT:

___Buttock

___Groin

___Front of thigh

___Side of thigh

___Back of thigh

___Calf

___Foot

6.	How far can you walk before LEG PAIN makes you stop and rest? (Check only one)
	___I cannot stand up	___1 or 2 blocks
	___Across the room	___1 or 2 miles
	___Across the parking lot	___I can walk as far as I want without leg pain

7.	Is there anything else that keeps you from WALKING ver far? (Check all that apply)
	___Back pain	___Shortness of breath
	___Chest pain	___Poor balance

What happens to your LEG PAIN with the following activities? (Check all that apply)

Lying down:

___Better

___Worse

___No change

Walking:

___Better

___Worse

___No change

Sitting:

___Better

___Worse

___No change

Bend forward:

___Better

___Worse

___No change

Standing:

___Better

___Worse

___No change

Bend back:

___Better

___Worse

___No change

What happens to your BACK PAIN with the following activities? (Check all that apply)

Lying down:

___Better

___Worse

___No change

Walking:

___Better

___Worse

___No change

Sitting:

___Better

___Worse

___No change

Bend forward:

___Better

___Worse

___No change

Standing:

___Better

___Worse

___No change

Bend back:

___Better

___Worse

___No change

Coughing:

___Better

___Worse

___No change

Sneezing:

___Better

___Worse

___No change

All patients should answer the following questions.

1. Are you recently leaking either urine or stool? YES / NO If YES since when? ______________________

2. Are you recently straining to urinate?? YES / NO If YES since when? ____________________________

3. Have you missed any work/school due to this problem? YES / NO How much? ______________________

4. Treatments for this particular problem have included: (Check all that apply)

___Supervised physical therapy

___Anti-inflammatory medication

Where? __________________

___Narcotic pain medication

___Manipulation or chiropractic treatment

___Epidural steriod injection:____times

Where? __________________

How long did relief last? _______________

___Daily neck/back exercises

___Facet joint injections/ablations:____times

___Massage and ultrasound

How long did relief last? _______________

___Traction, VAX-D, or DRX-9000

___Anti-inflammatory medication

___TENS unit or RS muscle stimulator

How long did relief last? _______________

___Back brace or neck collar

___Other:_________________________

5. List pain medicines and dose taken for this problem: ___NONE _______________________________
__________________________________________________________________________________
__________________________________________________________________________________

6. Previous doctors seen specifically about this problem: ___NONE

Doctor's Name	Specialty	City (if not Rockford)	Treatments
____________________	_______________	____________________	____________________
____________________	_______________	____________________	____________________
____________________	_______________	____________________	____________________

7.	What tests have you had for your problem? Please list the most recent date and location. ___NONE
	X-rays	______________________________	MRI	______________________________
	Myelogram	______________________________	EMG	______________________________
	CT scan	______________________________	Bone scan	______________________________

F. Past Medical History (Check all that apply) ___NONE
_Heart attack __Angina __Heart failure __High blood pressure __Stroke __Vascular disease __High cholesterol __Organ transplants __Diabetes How long?_____	__Asthma __Chronic bronchitis __Emphysema __Pneumonia, frequent __Tuberculosis __Dialysis __Kidney stones __Blood clot in legs __Blood clot in lungs __Bleeding disorders	__Sickle cell disease __Anemia __Stomach ulcers __Hepatitis __Parkinson’s disease __Polio __Neuropathy __Alcoholism __Mental illness __HIV/AIDS	__Osteoporosis __Fibromyalgia __Rheumatoid arthritis __Gout __Lupus __Ankylosing spondylitis __Cancer of __Injury of __OTHER:

G. Past Surgical History (List all previous surgeries, especially any surgeries
on neck, chest, or back; write on back if needed) ___NONE
                  Operation                                                          Surgeon                                         Date
_____________________________________    __________________________      ___________________
_____________________________________    __________________________      ___________________
_____________________________________    __________________________      ___________________
_____________________________________    __________________________      ___________________
_____________________________________    __________________________      ___________________
_____________________________________    __________________________      ___________________
H. Review of Systems (Check all that apply) ___NONE

PATHOLOGIC __Fevers or chills __Night sweats __Pain worse at night __Unusual weight loss __Sudden weight gain __No position of relief __Pain no better with rest __Feel lump in buttock __Feel lump in abdomen CARDIOVASCULAR __Heart or chest pain __Abnormal heartbeat __Swollen ankles or feet __Freq. night urination __Poor circulation __Short of breath if flat __Short of breath with exercise	PULMONARY __Wheezing __Persistent cough __Green/yellow sputum __Sinus infections __Bad or loud snoring __Frequent hoarseness GASTROINTESTINAL __Difficulty swallowin __Nausea or vomiting __Frequent diarrhea __Blood in stool __Very dark or tar stool __Ulcers NEUROLOGIC __Burning pain __Shingles/herpes zoster __Change of vision __Double vision	__Frequent headaches __Blackouts or seizures __Loss of memory __Loss of hearing __Ringing in ears __Nervous exhaustion __Depression or anxiety HEMATOLOGIC __Frequent nose bleeds __Easy bruising/bleeding __Gums bleed easily __Blood clots in legs __Blood clots in lungs RHEUMATOLOGIC __Bad morning stiffness __Red or swollen joints __Broken collarbone __Rashes or skin changes __New moles/dark spots	CONSTITUTIONAL __Frequent infections __Gum or tooth problems __Anorexia or bulimia __Poor nutrition __Very low energy GENITOURINARY __Swollen lymph glands __Difficulty urinating __Burning on urination __Frequent urination __Blood in urine __Leaking urine Women only: __Irregular periods __Vaginal discharge __Breast lumps or discharge
Have you ever had an infection with drug-resistant bacteria, e.g. methcillin resistant Staphyloccocus Aureus (MRSA) or vancomycin-resistant enterococcus (VRE)? YES / NO
I. Family History (Check all that apply) ___NONE ___UNKNOWN
__Scoliosis __Severe neck problems __Severe back problem	__Cancer (Type_______) __Heart attack __Stroke	__Bleeding disorders __Blood clots __Kidney failure	__Diabetes __Alcohol dependence __Mental illness

J. Medications (List dose and schedule, write on back if needed) ___NONE

      Any blood thinners (inc. aspirin)? YES / NO               Any cholesterol-lowering medicines? YES / NO
      List:________________________________             List: ________________________________
     Any osteoporosis medicines? YES / NO                     Are you taking calcium and vitamin D? YES / NO
     List:________________________________             List: ________________________________
OTHER:

K. Allergies to Medications ___NONE
      Medication                                                                  Type of Reaction (i.e., what happens?)
________________________________________   _____________________________________________
________________________________________   _____________________________________________
________________________________________   _____________________________________________
________________________________________   _____________________________________________
Any allergy to latex or bananas? YES / NO                Any allergy to nickel or metals/jewelry? YES / NO
L. Social History:
1. Work status: ___Homemaker      ___Student            ___Working (list occupation):__________________
                          ___Retired              ___Sick leave        ___Not working
                          ___On long-term disability or SSI         ___Applying for long-term disability or SSI
2. Marital Status:   ___Married         ___Single               ___Co-habitating
                              ___Divorced       ___Widowed
3. Number of living children:______ Number of children living locally:______
4. I live:             ___Alone                I live with:______________________________
5. Tobacco use: ___Never               ___Cigarettes        ___Cigars            ___Pipe            ___Chew
                        ___Packs per day for ______years      ___I QUIT using tobacco ___years ago
6. Alcohol use:   ___Never               __# of drinks/day        __# of drinks/week
                           ___Alcoholic (drunk daily)                    ___Recovering alcoholic
7. Drug use:       ___Never               ___Currently          ___Past               ___Former addict/rehab patient
8. Because of this problem, I HAVE FILED a:               ___Lawsuit          ___Workers’ compensation claim
9. Because of this problem, I MAY / WILL FILE a:       ___Lawsuit          ___Workers’ compensation claim
Patient Signature:___________________________________________     Date:_______________________

Pediatric and Adolescent Scoliosis/Kyphosis Questionnaire
Only fill out this form if you are seeing the doctor for SCOLIOSIS or KYPHOSIS.
NAME:_________________________________________________________      DATE:_________________
BIRTHDATE:_____________ AGE:_____     HEIGHT:____ft.   ____in.                    WEIGHT:____________lbs.
Approximate growth in last 6 months:    ________________
Height of mother:          ____________
Height of father:            ____________
Height of siblings:          ___________________________________________________
Any relatives with scoliosis/kyphosis?    _________________________________
How was scoliosis/kyphosis discovered?           _________________________________
Previous treatment for scoliosis/kyphosis           _________________________________
Previous surgeons seen for condition:    _________________________________
Have you had your first menses/period?            YES / NO        Approximate start date?_____________
Are your menses/periods regular?                     YES / NO
How old was your mother when her mense/periods began?_____________________________

How do you feel about how: 0 1 2 3 4 5 6 7 8 9 10
your spine looks? No problem Somewhat unhappy Very unhappy