SpinalSurgeryMexico Questionnaire

SPINE PATIENT QUESTIONNAIRE

Please fill out each field. Thank you
If you want to appoint a FREE phone consult call: +1(772)419-8061.

Or email us: gregorypope@spinalsurgerymexico.com
GENERAL INFORMATION
Name*

PrefixFirst NameLast
Date of Birth*

MonthDayYear
Gender*
Height*
Body Weight*
Age*
Years old
Right or Left handed*
Where do you currently live?*
City and state/region
PAIN DESCRIPTION
On the body diagrams use the appropriate pencil to mark where you feel the following sensations:

- Aching pain
- Pins and Needles
- Stabbing Pain
- Numbness

1. Click the black square icon and pick a color.
2. To draw: click on a spot, keep the pressure and drag over your pad (or use the mouse to move cursor around).
Graphic description of pain*
From 1 to 10, please indicate how severe your pain is now.*
0 = No pain / 10 = Worst pain
1. When did your present pain start? *

MonthDayYear
2. Is your pain due to a work-related injury?*

NoOther
3. Is your pain due to an auto accident injury?*

NoOther
4. Have you had similar pains in the past?*

NoYes
5. How did your pain start? Please check (x) all that apply to you.*

No apparent causeSuddenlyGraduallyBendingLiftingTwistingPushingPullingAfter a fallOther
6. Please describe how your pain started. *
7. Have you been hospitalized or seen in the Emergency Room for your pain?*

NoOther
8. What activities make your pain worse? Please check (x) all that apply to you.*

NoneLyingSittingEarly morningEnd of dayStandingWalkingTwistingExercise (during)Exercise (after)Bending forwardBending backwardCoughingSneezingOther
9. What reduces your pain? Please check (x) all that apply to you.*

NoneLyingSittingStandingWalkingRestBending forwardBending backwardExercisePain pillsHeat/coldMassagePhysical therapyChiropractic treatmentOther
10. What types of treatment have you had? Please check (x) all that apply to you.*

NonePhysical therapyEpidural steroid injectionsTrigger point injectionsFacet injectionsPool therapyChiropractic treatmentsOther
11. Review of symptoms. Please check (x) all that apply to you.*

Numbness/tingling of arms or legsBladder/bowelPsychiatric/emotionalDifficulty with hands or buttonsWeakness of arms or legsSexual difficultiesEndocrine/hormonalBlurry vision/headachesNight pain/difficulty sleepingChest pain/short of breathFever, chills or weight lossSkin rashesOther
DIAGNOSTIC TESTS

12. Have you had any of the following diagnostic studies?*

	NEVER	YES	IF YES (WRITE DATE PERFORMED)
Diagnostic X-rays
CT (computed tomography) scan
MRI (magnetic resonance image)
Myelogram
Discogram
EMG (electromyogram)/NCV (nerve conduction velocity)
Other (name of study and date)

13. Have you had surgery for this pain or similar pain?*
Describe the type of surgery you had, when/where performed; name of the surgeon.
Please attach any diagnostic studies / tests that may be helpful for your consultation.

Browse Files
Attach studies / tests if possible Cancelof
MEDICAL HISTORY
ILLNESSES / CONDITIONS. Please check (x) the box next to any illnesses or problems that apply to you.*

NoneArthritisAsthma/emphysemaBleeding/bruising problemsCancerDiabetesEpilepsy/seizuresHeart troubleHigh blood pressureKidney diseaseLiver disease/hepatitisSickle cell anemiaSkin rashes/lesionsStrokeThyroidUlcers/refluxOther
PAST SURGICAL HISTORY. Please check (x) the box next to any surgical procedures that you have had.*

NoneCervical spine/neckLumbar spine/low backAppendixBreastBowel/hemorrhoidCardiac stentExtremities/arms or legsGall bladderHeartHerniaKidneyLiverLungProstateStomachThyroidTonsilsUterus/ovaries/gynOther
ALLERGIES. Please check (x) the box next to any allergies that apply to you.*

None knownPenicillinSulphaIodineFoods or dyesOther
Do you have difficulty taking anti-inflammatory medications? *

NoYesDon't know
Medications currently taking*
Please list name of drug, dosage & how often taken, or type NONE.
FAMILY HISTORY. Please check (x) the box next to any disease diagnosed in your blood relatives.*

NoneBleeding problemsCancerDiabetesHeart diseaseSickle cell anemiaOther
WORK AND HABITS
Tobacco use*

NoOther
Alcohol use*

NoOther
Non-prescribed medications & recreational drugs*
Please name which ones, or type NONE.
Work status*
What is your occupation?*
Is this the same occupation you had before your injury?*

NoYesN/A
If NO to last question, what was your previous occupation?
Are you still working? *

NoYesN/A
If you answered NO to previous question, what was last day on the job?*

MonthDayYear
If working, are you at full duty or light duty? *

Full dutyLight dutyN/A
How should we contact you?
Please provide email & telephone number with city/country code.
Email*
Please, no Yahoo nor AOL addresses, to avoid you being flagged as Spam.
Phone Number*

Area CodePhone Number
Observations / details
Provide any piece of information that could be useful for your consult.
Current Date*

MonthDayYear
Should be Empty:

SPINE PATIENT QUESTIONNAIRE

If you want to appoint a FREE phone consult call: +1(772)419-8061.

GENERAL INFORMATION

PAIN DESCRIPTION

DIAGNOSTIC TESTS

MEDICAL HISTORY

WORK AND HABITS