PATIENT HEALTH HISTORY FORM NEUROSURGERY
PATIENT INFORMATION
Primary Reason For Your Visit?
Name:
DOB:
Occupation:
Ethnicity:
Caucasian
African American
Asian
Hispanic
Referring Doctor:
Primary Doctor:
Primary Insurance:
Pharmacy:
SYMPTOMS Describe your symptoms. Please fill out and use the diagram below to assist you in your description. Mark on the drawings according to where you hurt. Please indicate on the drawing where you feel any of the following symptoms by placing the marks shown here on the DIAGRAM KEY.
DIAGRAM KEY Numbness=N Ache=A Weakness=W Burning=B Stabbing=S Pins & Needles=P
How Long Have You Had These Symptoms?
Have you EVER had any of these symptoms in the past?
Yes
No
Pain Score on your WORST day (0=no pain to 10=worst)?
Do you have any weakness?
Yes
No
Where:
Do you have numbness/tingling?
Yes
No
Where:
What Makes Your Pain Better?
Laying
Sitting
Standing
Walking
Rest
Heat
Ice
Ice
Position Change
NSAIDs (Ibuprofen, Celebrex, etc.)
Narcotics (name):
What Makes Your Pain Worse?
Laying
Sitting
Standing
Walking
Twisting
Lifting
Pushing/Pulling
Pushing/Pulling
Sit to stand
Getting out of bed
Carrying
Previously Tried Treatment(s):
*Physical Therapy
No
Yes (When?)
Was it helpful?
Provider name and office:
What area were you being treated for?
*Steroid Injections
No
Yes
(When?)
Was it helpful?
Provider name and office:
Location of Injection:
*Stimulator
No
Yes
(When?)
Was it helpful?
Type:
Spinal
Peripheral
Provider name and office:
*Opioid Pain Pump
No
Yes (When?)
Was it helpful?
Provider name and office:
Other Therapies:
Chiropractic
Chiropractic
Massage
At Home Exercises
Aquatic
Acupuncture
FOR OFFICE USE ONLY
Height:
Weight:
Blood Pressure:
Pulse:
O2 Sat (%)
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MEDICATIONS & ALLERGIES
Today's Date:
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Month
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Day
Year
Date
Patient Name:
Date of Birth:
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Month
-
Day
Year
Date
Emergency Contact:
Relationship:
ALLERGIES
ALLERGIES
Rows
ALLERGY
REACTION
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2
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4
5
MEDICATIONS
MEDICATIONS
Rows
MEDICATION
DOSAGE
HOW OFTEN
WHO PRESCRIBES THIS?
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2
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9
10
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20
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Authorization to Communicate
Patient Name:
Date of Birth:
-
Month
-
Day
Year
Date
Privacy regulations require us to have a release signed by our patients so we may speak with family members, friends and other relations regarding your medical treatment and patient financial information. Each person you wish to be considered a contact must be listed individually by name (including a spouse or significant other).
Please print name, relationship and telephone number for each person to whom you are authorizing release of your private health care information and account balances.
Name
Relationship
Phone Number
Format: (000) 000-0000.
Name
Relationship
Phone Number
Format: (000) 000-0000.
This release of information authorization is valid until
authorization will expire one year from the date it was signed.
20
-
Month
-
Day
Year
Date
If no date is listed, this
NeuroSpine Group, LLC, has my authorization to:
Leave medical information on my home/cell voicemail
Y
N
Contact me at my place of employment
Y
N
Leave medical information on voicemail at my place of employment
Y
N
You have the right to revoke this Authorization at any time, provided that you do in writing. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission. The information used or disclosed pursuant to this Authorization may be subject to re- disclosure by the recipient and no longer be protected under federal law. Your health care and payment for health care cannot be conditioned upon receipt of this signed Authorization.
Signature (Parent / Legal Representative)
Date
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Month
-
Day
Year
Date
Printed Name
Relationship to Patient
74B Centennial Lp Ste 300 Eugene OR 97401 | Office: (541) 686-3791 Fax: (541) 686-3795
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Behavioral Contract
As you know, a successful patient-physician relationship is based on trust and mutual respect. Here at NeuroSpine we expect all our patients to be respectful to all staff members and physicians, and we will provide you with the same. We value you as a patient and want to continue to provide you with high-quality care and service. Consistent with this goal, we will not tolerate any of the following from patients or family members:
Drug seeking or addictive behaviors, including any drug or alcohol use on the property
Any physically threatening behavior
Patterns of inappropriate behavior (e.g., verbal abuse, yelling, profanity, etc.)
Any rude, demeaning, or manipulative behavior
Any damage to property
Continued noncompliance issues (e.g., repeated no shows; agreeing to, but not complying with, a treatment plan; etc.)
When any of this behavior is present, we will terminate our patient-physician relationship as of the date of the first occurrence. If necessary, we will help in transitioning to a new health care provider. The next thirty (30) days after you have been terminated from our practice, your physician at NeuroSpine will provide only emergency services to you. In that event, you are responsible for contacting other spine physicians' offices to arrange for your continuing medical care.
Initial:
I have read and understood, and I agree to the above expectations. I understand that failure to meet these expectations may result in the immediate termination of the relationship between me and NeuroSpine.
If you chose not to sign, please let one of our staff members know, so we can have your medical records sent to another Spine Surgeons Office.
Patient Signature
Date
-
Month
-
Day
Year
Date
74-B Centennial Loop Ste 300 | Eugene, Oregon 97401 | Office: 541-686-3791 | Fax: 541-686-3795
AUTHORIZATION FOR MARKETING
I, authorize Northwest Neurospine Institute LLC dba Two Rivers Surgery Center and The Neurospine Group LLC (collectively, the Practice) to use and disclose my protected health information, including my name, personal testimonials, treatment history, likeness, image, voice, and appearance, to be used in video tapes, video files, film, slides, photographs, audiotapes, or other media now known or later developed (Product) for | marketing purposes, which may then be released to the general public.
I have reviewed and I understand this Authorization. I am 18 years of age or older and I am competent to contract in my own name. Unless revoked earlier, this Authorization will expire upon my death.
Note:
(1) You have the right to revoke this Authorization at any time, provided that you do so in writing. If you do so, Practice will make all reasonable efforts to stop publishing or reproducing the Product, though it will not be able to remove any Product previously published from the media in which it was released. To revoke this Authorization, please contact Practice; (2) Practice cannot and will not condition provision of services or treatment to you on whether or not you decide to sign this Authorization; and (3) By signing this Release, you understand that the information disclosed pursuant to this Authorization. may be subject to re-disclosure by recipients of the Product, and at that point it will no longer be protected under federal law.
Dated:
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Month
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Year
Date Picker Icon
By:
062918
CERVICAL
Patient Name:
Date of Birth:
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Month
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Day
Year
Date
Date:
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Oswestry Cervical Pain Disability Questionnaire
Instructions
This questionnaire has been designed to give the doctor information as to how your pain has affected your ability to manage in everyday life. Please answer every section and select only one box which applies to you. We realize you may consider two statements in any one section, but please mark the box which most closely describes your problem right now.
Section 1—Pain Intensity (select only one)
Pain Intensity
I have no pain at the moment.
The pain is very mild at the moment.
The pain is moderate at the moment.
The pain is fairly severe at the moment.
The pain is very severe at the moment.
The pain is the worst imaginable at the moment.
Section 4—Walking (select only one)
Walking
Pain does not prevent me walking any distance.
Pain prevents me from walking more than 1 mile.
Pain prevents me from walking more than 1/4 mile.
Pain prevents me from walking more than 100 yards.
I can only walk using a cane or crutches.
I am in bed most of the time.
Section 2—Personal Care (washing, dressing, etc)
Personal Care
I can look after myself normally with no extra pain,
I can look after myself normally but it is very painful.
It is painful to look after myself; I am slow and careful.
I need some help but manage most of my personal care
I need help every day in most aspects of my care.
I don't get dressed, I wash with difficulty and stay in bed.
Section 5—Sitting (select only one)
Sitting
can sit in any chair as long as I like.
I can only sit in my favorite chair as long as I like.
Pain prevents me from sitting more than 1 hour.
Pain prevents me from sitting more than 1/2 hour.
Pain prevents me from sitting more than 10 minutes.
Pain prevents me from sitting at all.
Section 6—Standing (select only one)
Standing
I can stand as long as I want without extra pain.
I can stand as long as I want but it gives me extra pain.
Pain prevents me from standing for more than 1 hour.
Pain prevents me from standing for more than 1/2 hour.
Pain prevents me from standing for more than 10 min.
Pain prevents me from standing at all.
Section 3—Lifting (select only one)
Lifting
I can lift heavy weights without extra pain.
I can lift heavy weights but it gives me additional pain.
Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned, i.e. on a table.
Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned.
I can only lift very light weights.
I cannot lift or carry anything at all.
NeuroSpine Institute | 74B Centennial Loop | Eugene, OR 97401 | Phone 541-686-3791 | Fax 541-686-3795
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