Follow Up Form for Neurosurgery Spine patients

Follow Up Form

Neurosurgery Spine
Patient Name*

First NameLast Name
Date of Birth

MonthDayYear
When did your pain first start? (date or approx. month/year):
When did it worsen? (date and event, if applicable)
Rate the severity of your pain on a scale from 1 to 10, with 1 being the least painful and 10 being the most severe:
Type of pain (select all that apply):

AchingBurningCrampsDullNumbnessSharpShootingStiffnessSwellingTinglingThrobbing
Does the pain interfere with any of the following activities of daily living? (Select all that apply)

BathingDressingFeedingFood preparationGroomingHouseworkSleepToilet hygieneWork
How often are you having pain?
Activities or movements that are painful to perform: (select all that apply)

BendingLying downSittingStandingWalking
In the past 6 months, have you received any formal therapy for this condition?
If yes, when?
Do you perform home exercises/stretches for this condition?
Have you received an Epidural Steroid Injection for this condition?
If yes, when?
What percentage relief did the injection provide?
For how long? (hours, days, weeks, months)
When did the pain return?

MonthDayYear
Date

Rows	Have you tried any of the following for pain relief (check all that apply)?	Did this provide relief?	Name of Medication
Heat
Ice
Over the Counter Medications
Prescription