Neuro Questionnaire

710 S Broadway, Ste 212, Walnut Creek, CA 94596

4200 18th Street, Ste 103, San Francisco, CA 94114

2929 Summit Street, Ste 103, Oakland, CA 94609

4439 Stoneridge Road, Ste 110, Pleasanton, CA 94588

6611 Folsom-Auburn Road, Ste F, Folsom, CA 95630

291 S La Cienega Blvd, Ste 108, Beverly Hills, CA 90211

Telephone and Central Fax (925) 388-9800

Patient Name*

Today's Date

Date of Birth*

Date

Age*

What is your dominant hand:*

RightLeft

What is your Height:*

What is your Weight:*

HISTORY OF PRESENT INJURY / CHIEF COMPLAINTS:*

PRESENTING PROBLEMS: Check all that applies

If your Problem is Pain, then Rank the Area of Pain with #1 being the main problem:

Rows	Rank #1, #2, etc
Head and Face
Neck
Shoulders
Arms and Elbows
Wrists and Hands
Chest and Abdomen
Pelvic
Upper Mid Back
Low Back
Hips
Knees
Ankles and Feet

NEXT FOUR SECTIONS are NECK PAIN, UPPER LIMB PAIN, LOW BACK PAIN, LOWER LIMB PAIN. You need to ONLY answer the sections that apply to you. Eg. If your Neck Pain radiates to your arm, fill out only the NECK section. Or if you have an elbow injury, then fill UPPER LIMB PAIN only.

NECK PAIN: (Starts at neck and radiates to arms)

Date NECK PAIN Began

Date

How did NECK PAIN begin? Accident, injury, illness, gradual onset

FREQUENCY OF NECK PAIN:

Rows	Without Medications or Treatments
Constant more than 90%
Frequent more than 75%
Intermittent 50% of time
Occasional 25% of time

PAIN SCALE OF NECK PAIN: One to 10

Rows	Without Medications or Treatment
9 - Severe Can't move
8 ModSevere Freq lying down
7 ModSevere Limits activity to less than 1/4 hr
6 - Moderate Limits activity to less than 1/2 hr
5 - Moderate Limits activity to less than 1 hr
4 - Moderate
3 - Slight Pain with activity

CHARACTER of NECK PAIN - check all that applies

Dull or AchySharp or StabbingShootingBurning or Throbbing

NECK PAIN Radiates to:

Rows	Pain Travels to
Head Right
Head Left
Upper Back Right
Upper Back Left
Shoulder/Arm Right
Shoulder/Arm Left
Wrist/Hand Right
Wrist/Hand Left

Associated with:

Numbness and tinglingWeakness

Aggravating and Relieving Factors to Neck Pain:

Rows	Aggravating Factors
Sitting
Standing or Walking
Bending, Lifting
Lying down

Relieving Factors to Neck Pain:

Rows	Relieving Factors
Sitting
Standing or Walking
Lying down

NECK PAIN SYMPTOMS ARE

ImprovingWorseningStaying same

UPPER LIMB PAIN: (Starts in Upper Limbs)

Date Upper Limb Pain Began:

Date

How did Upper Limb Problem began:

UPPER LIMB PAIN (Separate from Neck, starts in Upper Limbs - check where the problems are)

Rows	Right	Left
Shoulder
Elbow
Wrist
Hand

FREQUENCY OF UPPER LIMB PAIN:

Rows	Right Side	Left Side
Constant more than 90%
Frequent more than 75%
Intermittent 50% of time
Occasional 25% of time

LeftPAIN SCALE OF UPPER LIMB PAIN: One to 10

Rows	Right Side	Left Side
9 - Severe Can't move
8 ModSevere Pain worse from moving
7 ModSevere Painful to lift 10 pounds
6 - Moderate
5 - Moderate Painful to Lift and Carry 10 pounds
4 - Moderate
3 - Slight Able to do things, but with pain

CHARACTER OF UPPER LIMB PAIN - check all that applies

Rows	Right Side	Left Side
Dull or Achy
Sharp or Stabbing
Shooting
Burning or Throbbing

UPPER LIMB PROBLEM radiates to and/or associated with:

Rows	Pain
Head Right
Head Left
Shoulder Right
Shoulder Left
Arm Right
Arm Left
Elbow Right
Elbow Left
Wrist Right
Wrist Left
Hand Right
Hand Left

ASSOCIATED WITH

Rows	Right Side	Left Side
Numbness & Tingling
Weakness

Aggravating and Relieving Factors to UPPER LIMB Pain: Check if applies

Rows	Aggravating	Relieving
Sitting
Standing / Walking
Lifting
Lying down

UPPER LIMB SYMPTOMS ARE

ImprovingWorseningStaying same

LOW BACK PAIN: (Starts at back and radiates to legs)

Date LOW BACK PAIN Began

Date

How did LOW BACK PAIN begin?

FREQUENCY of LOW BACK PAIN

Rows	Without Medications or Treatment
Constant more than 90%
Frequent more than 75%
Intermittent 50% of time
Occasional 25% of time

PAIN SCALE OF LOW BACK PAIN: One to 10

Rows	Without Medications or Treatment
9 - Severe Can't move
8 ModSevere Freq lying down
7 ModSevere Limit < 1/4 hr
6 - Moderate Limit < 1/2 hr
5 - Moderate Limit < 1 hr
4 - Moderate
3 - Slight Pain with activity

CHARACTER of LOW BACK PAIN - check all that applies

Dull or AchySharp or StabbingShootingBurning or Throbbing

LOW BACK PAIN Radiates to:

Rows	Pain
Midback Right
Midback Left
Hip Right
Hip Left
Thigh Right
Thigh Left
Lower Leg Right
Lower Leg Left
Foot Right
Foot Left

ASSOCIATED WITH:

Numbness and TinglingWeaknessIrritable Bladder or Bowel

Aggravating and Relieving Factors to LOW BACK PAIN:

Rows	Aggravating	Relieving
Sitting
Prolonged Standing or Walking
Bending or Lifting
Lying down
Use of Cane

LOW BACK SYMPTOMS ARE

ImprovingWorseningStaying same

LOWER LIMB PAIN: (Starts in legs and radiates to legs)

Date LOWER LIMB PAIN Began

Date

How did the LOWER LIMB PAIN begin?

LOWER LIMB PAIN:

Rows	Right	Left
HIP
KNEE
ANKLE
FOOT

FREQUENCY of LOWER LIMB PAIN

Rows	Right Side	Left Side
Constant more than 90%
Frequent more than 75%
Intermittent 50% of time
Occasional 25% of time

PAIN SCALE OF LOWER LIMB PAIN: One to 10

Rows	Right Side	Left Side
9 - Severe Can't move
8 ModSevere Painful just moving
7 ModSevere Painful to stand
6 - Moderate Limits walking to less than 1/2 hr
5 - Moderate Limits walking to 1 hour
4 - Moderate
3 - Slight Able to walk but with pain

CHARACTER OF LOWER LIMB PAIN - check all that applies

Rows	Not Satisfied	Somewhat Satisfied
Dull or Achy
Sharp or Stabbing
Shooting
Burning or Throbbing

LOWER LIMB PAIN Radiates to:

Rows	Pain
Hip Right
Hip Left
Thigh Right
Thigh Left
Lower Leg Right
Lower Leg Left
Foot Right
Foot Left

ASSOCIATED WITH:

Rows	Right Side	Left Side
Numbness and/or Tingling
Weakness

Aggravating and Relieving Factors to LOWER LIMB PAIN:

Rows	Aggravating	Relieving
Sitting
Standing or Walking
Lying down
Use of cane

LOWER LIMB SYMPTOMS ARE

ImprovingWorseningStaying same

Date when symptoms began

Date

Accident or Illness?

Pain throughout Day:

Rows	Morning	Afternoon	Evening
When is the pain better?
When is the pain worse?

Does the Pain impact:*

Rows	Yes	No
Can you Walk, Bathe nd Dress without assistance?
Can you sit through a movie?
Can you walk without assistance for over 30 minutes?
Can you get off the floor without using your hands?
Can you lift a heavy bag of groceries without problems?
Can you carry a 10 pound bag 50 feet?
Can you do all your recreational and work activities?
Does the pain affect relationships with family and friends?

PRIOR TREATING DOCTORS:

Rows	Name of Doctor and City
Primary Care Physician
Pain Management
Specialist/Surgeon
Chiropractor or PT or Acupuncturist
Chiropractor or PT or Acupuncturist

PRIOR WORKUP:*

Rows	No	Yes	MM/YR done	Results of Abnormal Findings
Labs
X-rays
MRI's
EMG Nerve Studies

PRIOR TREATMENT FOR PRESENT PAIN*

Rows	No	Yes	Month/Year	Did it help?
Physical Therapy
Exercise
Chiropractic
Osteopathy
Acupuncture
Trigger Points Injections
Joint Injections
Epidural/ Facet/ Nerve Blocks
PRP / Stem Cells
Surgery / Stimulator

PAST MEDICAL HISTORY: Medical problems treated now or in past*

Rows	Yes	No
Seizure
Stroke
Glaucome
Thyroid
Diabetes
High Blood Pressure
High Cholesterol
Heart Disease or Irregular Rhythm
COPD or emphysema
Asthma
Heartburn, GERD, or Reflux Gastritis
Pancreatitis
Liver Disease, Hepatitis, Gall Bladder
Kidney Disease
Prostate problems
Pelvic / Genital problems
Arthritis
Chronic Pain
Chronic Infection
Cancer
Addiction
Depression
Anxiety
ADHD

Have you had any Surgeries?*

YesNo

PAST SURGERIES:

Rows	Month/Year	Name of Operation Performed	Did it help?
Operation 1
Operation 2
Operation 3
Operation 4

FAMILY HISTORY:

Rows	Mother	Father	Siblings	Children
Thyroid
Diabetes
Hypertension
Heart Disease
Stroke
Arthritis
Autoimmune
Cancer
Addiction
Depression Anxiety

SOCIAL HISTORY:*

Rows	Yes	No
Are you married or live with a partner?
Do you live with other people?
Do you have children?
Do you smoke cigarettes?
Do you drink alcohol daily?
Do you use any street drugs?

Do you have any ALLERGIES TO DRUGS OR ANESTHESIA:

YesNo

List Drugs Allergies:

Rows	Drug Name	Reaction (rash, swelling, short of breath
Drug #1
Drug #2
Drug #3

Are you taking any PRESENT MEDICATIONS, or Over-the-Counter Supplements?*

YesNo

PRESENT MEDICATIONS:

Rows	Medication	Strength	How Often	For What Condition	Prescribing Physician
Rx #1
Rx #2
Rx #3
Rx #4
Rx #5
Rx #6
Rx #7
Rx #8
Rx #9
Rx #10
Rx #11
Rx #12

Have you tried any Medications in the Past for your Pain?*

YesNo

PAST DRUGS USED for your pain:

Rows	Medication	Strength	Did it help?	Why did you stop?
Rx #1
Rx #2
Rx #3
Rx #4

REVIEW OF SYSTEMS (General Health): Do you have any problems with*

Rows	Yes	No
Fever, Chills, Sweating
Sleeping less than 6 hours
Headaches. Migraines.
Difficulties in Vision
Difficulties in Hearing
Nasal or Sinus Congestion. Nose bleeds. Unable to smell or taste.
Problems with teeth or gums. Sore throat. Swollen glands.
Chest pain. Rapid or irregular heart rate. Feet swelling.
Shortness of Breath
Wheezing. Coughing.
Nausea. Vomiting.
Heartburn. Abdominal pain.
Yellow jaundice
Diarrhea. Constipation.
Bright red blood in stool. Dark stool.
Poor libido
Pelvic pain.
Sexual Dysfunction (ED in men, FSD in women)
Frequent urination. Burning. Urgency. Weak Urine flow.
Wake up to urinate
Weakness. Fatigue.
Joint pain. Muscle pain.
Problems with Balance
Skin rashes. Acne. Moles. Easy Bruising.
Hair loss
Numbness. Tingling.
Seizures
Forgetful
Repeatedly or overly worried. Rapid thoughts.
Trouble falling asleep
Snoring
Feeling sad or depressed
Feeling hopeless, or suicidal thoughts.
Weight Loss, or Poor Appetite.
Weight Gain, or Excessive Appetite

Signed*

Today's Date

Vital Total Health Medical Group, Inc.

NEUROLOGY QUESTIONNAIRE