cnsrehab.com-New Patient PN Questionnaire

Outline Procedures for New Patients

Step One - All new patients are requested to fill out a personal health questionnaire prior to their appointment.
Step Two - Your consultation with a doctor to discuss your health concerns.
Step Three - Diagnostic neurologic and orthopedic examination procedures to determine if our care is appropriate for your condition.
Step Four - You will be advised if there is the need of any additional procedures such as X-rays, MRI, Cat Scan, ENFD or EMG.
Step Five - Treatment options will be discussed and initiated if appropriate. If you are not accepted for any reason, referrals to another provider may be necessary.

Confidential Patient Information
Name

First Name Last Name
Date

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell Phone
Email Address
example@example.com
Date of Birth

Month Day Year
Height
Weight
Insurance Information: ( Please bring a copy of your current card so we may check benefits for you)
Referred by:

Advertisement Physician
Family Physician: (we will send information to your doctor regarding yourtreatment here)

First Name Last Name
Medical Specialist(s): (neurologist,podiatrist, etc.)
DRUG / FOOD ALLERGIES:
Do you have an internal pacemaker or defibrillator? (cardiologist permission required before any treatment may be performed.)

Yes No
Marital Status:

Married Single Divorced Widow/er
Spouse’s Name

First Name Last Name
Children:

Yes No
If yes: Children’s ages
IN CASE OF EMERGENCY
Please Contact: Name

First Name Last Name
Best Number to Contact

Area Code Phone Number

Only for Women:

Yes/No

PREGNANT

HORMONE REPLACEMENT

CURRENTLY TAKING PHARMACUETICAL BIRTH CONTROL

PAST PHARMACEUTICAL BIRTH CONTROL

How long?

CNS Rehab

6200 S 58th Street, suite A
Lincoln, NE 68516

(402) 420-2677

CNS Rehab Neuropathy Case History
Name

First Name Last Name
Date

Month Day Year
TELL US ABOUT YOUR SYMPTOMS:
SYMPTOM
LOCATION
SYMPTOM ONSET (when did you first notice these symptoms):
CAUSE OF SYMPTOMS:

Unknown (idiopathic) Diabetes Chemotherapy Trauma
PAIN QUALITY: Over the past two weeks, did the pain have any of the following features?

If yes

Rate on 0-10 scale

Sharp Pain

Numbness

Tingling

Hot / Burning

Electric shocks

Other

PAIN IN SCIATICA AREA: Over the past week, which item best describes your pain?

Not felt in buttocks, back of thigh or outside of thigh Felt in buttocks but not in back/outside thigh Felt in buttocks and back/outside thigh Felt in back/outside of thigh but not in buttocks
SYMPTOMS ARE AGGRAVATED BY OR MORE OFTEN SEEN WITH:

Cold Heat Light touch Lying down Night time Shoes Sitting Standing up initially Static standing Walking
WHAT RELIEVES YOUR SYMPTOMS (even a little)?

Cold / Icing area Heating area Lying down Massage Marijuana CBD Sitting Standing Walking Stretching Wearing shoes Wearing orthotics / arch supports Wearing compression socks Medications – OTC Medications – prescribed Medications – injections
TREATMENTS YOU HAVE TRIED THAT DID NOT WORK FOR YOUR NEUROPATHY:

Local heat (i.e. heating pad) to painful area Local cold (i.e. icing) to painful area OTC (over-the-counter) pain killers Prescription painkillers Gabapentin (Neurontin) Lyrica (pregabalin) Ultram (tramadol) Lidocaine patch Chiropractic Acupuncture Physical Therapy Meditation Psychological counseling Antidepressants ( i.e. amitriptyline, nortriptyline, imipramine, sertraline, fluvoxamine, fluoxetine, paroxetine, desipramine, bupropion, citalopram, venlafaxine, duloxetine, mirtazepine, phenelzine, tranylcypromine, trazodone ) Anticonvulsants ( i.e. lamotrigine, carbamazepine, levetiracetam, oxcarbazepine, topiramate or zonisamide ) Injections by a Pain Specialist Internal Spinal Stimulator
ASSOCIATED SYMPTOMS: Do you experience any other symptoms that may be related to your pain?

Anxiety Depression Difficulty concentrating Difficulty walking Dizziness Fatigue Irritability Muscle weakness Poor balance Restless Leg(s) Sleeplessness / Insomnia
Sleeplessness / Insomnia – ave number of hours lost per night
MUSCULO-SKELETAL DISEASES: Have you ever been diagnosed by a healthcare professional as having any of the following musculo-skeletal conditions?

Ankylosing spondylitis Arthritis (osteoarthritis) Aseptic necrosis of hip Chronic bursitis Chronic ligament injury/problem Chronic separation of shoulder Chronic tendonitis Congenital dislocation of hip Degenerative disease of lower spine Degenerative joint disease Fibromyalgia Frozen shoulder Gout Herniated disk in lower back Iliotibial band syndrome Lower back pain syndrome Lumbo-sacral joint disease Osgood-Schlatter disease Osteochondritis dissecans Osteoporosis Plantar fasciitis (heel spur) Plica syndrome Poor alignment of vertebrae / pelvis Pseudogout Rheumatoid arthritis Rotator cuff problem Rcoliosis or kyphosis Shoulder impingement syndrome Slipped disk in lower back
HEADACHE / HEAD PAIN: Have you ever been diagnosed by a healthcare professional as having any of the following types of headache/pain in the head?

Chronic muscle contraction headache Chronic tension headache Dental abscess or sensitive teeth Migraine Temporal arteritis Temporomandibular joint (TMJ, TMD) Traction headache Vascular headache
VISCERAL DISEASES: Have you ever been diagnosed by a healthcare professional as having any of the following visceral diseases (diseases associated with internal organs such as the heart, gut or kidney)?

Angina Congestive heart failure (CHF) Gallstones Hiatal hernia Hypertension / high blood pressure Kidney disease or stones Liver disease / dysfunction Pleurisy Reflux (GERD) Ulcers of the stomach / intestines Uterus or ovary problems
NEUROLOGICAL DISEASES: Have you ever been diagnosed by a healthcare professional as having any of the following conditions that may be associated with neurological problems?

auto-immune nerve damage chronic regional pain syndrome (CRPS/RSD) chronic inflammatory demyelinating polyneuropathy (CIDP) excessive alcohol intake Guillain-Barré syndrome heavy metal or environmental toxicity hereditary neuropathy (e.g., Charcot-Marie Tooth disease) meralgia paresthetica mononeuropathy multiplex Morton’s neuroma multifocal mononeuropathy multifocal motor neuropathy nerve damage from medications (e.g., anticancer drugs, anticonvulsants, antivirals, antibiotics) nerve entrapment neuropathy neuralgia neurofibromatosis (von Recklinghausen's disease, NF1, NF2) pinched nerve polyneuropathy (sensory &/or motor) post-herpetic neuralgia sciatica shingles trigeminal neuralgia
OTHER DISEASES THAT MAY BE ASSOCIATED: Have you ever been diagnosed by a healthcare professional as having any of the following diseases?

cancer chronic infection complex regional pain syndrome (CRPS) connective tissue disorder (e.g., lupus or sarcoidosis) cytomegalovirus infection Epstein-Barr virus infection glaucoma herpes simplex virus infection HIV virus infection hypoglycemia Lyme disease multiple sclerosis other tumors paraneoplastic syndrome stroke thyroid disorder ulcerations of the skin (open wounds)
Vitamin deficiency
Diabetes:

Type I Type II
EMOTIONAL, PSYCHOLOGICAL OR PSYCHIATRIC PROBLEMS: Have you ever been diagnosed by a healthcare professional as having any of the following:

affective disorder dementia depression generalized anxiety disorder (GAD) hypochondriasis mania/hypomania/manic disorder manic-depressive disorder/bipolar disorder obsessive-compulsive disorder (OCD) panic disorder post-menopausal depression post-partum depression schizophrenia seasonal affective disorder (SAD) substance abuse
EMOTIONAL FACTORS IN PAIN: YOUR VIEW OF ANY EMOTIONAL COMPONENT TO YOUR PAIN:

YOU believe that your pain is totally related to your underlying physical disease and is NOT INFLUENCED BY EMOTIONAL OR PSYCHOLOGICAL FACTORS. YOU believe that your pain is caused by an underlying physical disease but is MADE WORSE BY EMOTIONAL FACTORS. YOU believe that your pain is MAINLY CAUSED BY EMOTIONAL OR PSYCHOLOGICAL FACTORS.
YOUR DOCTOR'S VIEW OF ANY EMOTIONAL COMPONENT TO YOUR PAIN:(regardless of whether you agree or disagree)

My doctor has NOT suggested that my pain may be related to emotional or psychological factors. My doctor has suggested that my pain is partly caused by an underlying physical disease but is MADE WORSE BY EMOTIONAL FACTORS. My doctor has suggested that my pain is MAINLY OR WHOLLY CAUSED BY EMOTIONAL OR PSYCHOLOGICAL FACTORS.
SURGERIES: Please list ALL surgeries you have had and the year it was performed.
TRAUMAS / ACCIDENTS: Please list ALL traumas, injuries, accidents or broken bones you have had, cause(s) and the year occurred.
MEDICATIONS: Please list ALL medications you are currently taking and the dosages (important). You may provide a list on a separate piece of paper if you would like.
MEDICATIONS: Please list ALL medications you are currently taking and the dosages (important). You may provide a list on a separate piece of paper if you would like.
SUPPLEMENTS: Please list ALL vitamins and/or nutritional supplements you are currently taking. You may provide a list on a separate piece of paper if you would like.
SOCIAL HISTORY:
Education:How many years of school have you completed?
Occupation:

Employed Homemaker Unemployed Retired
current occupation(s)
Previous Occupations/Jobs:
Disability:Are you disabled?

Yes No

Have you used any of the following substances?

Currently Use?

Previously Used?

Type/Amount/ Frequency

How Long? (Years)

If stopped, when? (Year)

Caffeine: coffee, tea, soda

Tobacco ‰

Alcohol: beer, wine, liquor

Recreational/Street drugs

Place a check mark (√) in the appropriate boxes to identify all illnesses/conditions which you know to have occurred in your blood relatives.

( Grand Parents-GP ,Father-F ,Mother-M, Brothers-B, Sisters-S ,Sons-sons ,Daughters-D )

Illness/Condition

sons

Describe

Cancer (type)

Heart Disease

Diabetes

Stroke/TIA

High Blood Pressure

High Cholesterol or Triglycerides

Liver Disease

Alcohol or Drug Abuse

Anxiety, Depression or Psychiatric Illness

Anesthesia Complications

Other – describe

How have others (friends, family members, etc.) been affected by your health condition?

No one is affected They tell me to do something Haven’t noticed any problem People avoid me
What are you afraid this might be (or beginning) to affect or will affect?

Job Kids Future ability Marriage Self-esteem Sleep Time Finances Freedom

CNS Rehab

6200 S 58th Street, suite A
Lincoln, NE 68516

(402) 420-2677

Should be Empty:

CNS Rehab Neuropathy Case History