Spine Clinic Form

1
What is your name?
First Name
Last Name
2
How old are you?
3
What is your gender identity?
Male
Female
Other
Prefer not to answer
4
What is your height and weight?
Please Select
Please Select
4'10''
4'11'
5'0''
5'1''
5'2''
5'3''
5'4''
5'5''
5'6''
5'7''
5'8''
5'9''
6'0''
6'1''
6'2''
6'3''
6'4''
6'5''
6'6''
Height
Please Select
Please Select
Under 100 lbs
110 lbs
120 lbs
130 lbs
140 lbs
150 lbs
160 lbs
170 lbs
180 lbs
190 lbs
200 lbs
210 lbs
220 lbs
230 lbs
240 lbs
250 lbs
260 lbs
270 lbs
280 lbs
290 lbs
300 lbs
Over 300 lbs
Option 3
Weight
5
What brings you in today?
Back pain
Neck pain
Arm pain
Leg pain
Shoulder joint pain
Knee joint pain
Hip joint pain
Buttock pain
Groin pain
6
How long has this been going on for?
Less than 1 month
2-3 months
More than 3 months
More than 1 year
More than 5 years
7
Was there any fall or trauma/injury that caused this?
YESNO
8
What happened?
Fall
Workplace injury
Car accident
Nothing happened
Heavy Lifting
Other
9
Is it getting better?
Getting better
Getting worse
About the same
10
Which side is worse?
Right
Left
Both
11
How bad is the pain right now?
Not bad
Moderate
Severe
I can tolerate it
12
What have you tried so far?Check all that apply
Physiotherapy
Chiropractic
Accupuncture
Pain Medications
Injections
Brace
Previous spine surgery
Nothing
13
Did it help?
YESNO
14
Have you had an MRI done?
YESNO
15
Have you had other imaging tests done?Check all that apply
X-ray
CT Scan
MRI
EMG/ Nerve Conduction
None
16
Have you tried any of the following pain medications?
Lyrica/Pregabalin
Gabapentin
Tylenol
Advil
Celebrex
Naproxen
Hydromorphone
Tylenol 3
Baclofen
Ketorolac and diclofenac
17
Are you currently working?
Working normally
Modified duties
Off work
Retired
Disability
18
What are you mainly hoping for from this visit?
Want surgery
Avoid surgery
Reassurance
Get more information
Try less risky options
19
Do you get any pain or electric shocks down your arm?
YESNO
20
What about any numbness or tingling in your arms?
YESNO
21
Do you get any pain or electric shocks down your leg?
YESNO
22
What about any numbness or tingling in your legs?
YESNO
23
Do your legs feel heavy or tired when walking/standing for a long time?
YESNO
24
Does it feel better when you sit down or lean on something like a shopping cart?
YESNO
25
How far can you walk before you have to sit down?
Less than 1 block
About 1 block
More than 1 block
No trouble walking
I can barely walk
26
How long can you stand for before you have to lean on something?
Less than 5 minutes
5-10 minutes
10-20 minutes
20-30 minutes
30 minutes to 1 hour
Over 1 hour
27
Where does the pain travel?
Into the hip/buttock
Into the knee
Into the ankle/foot
Only in the back
28
Where does the pain go?
Thumb/index finger
Middle finger
Ring/Little finger
Into the shoulder
Into the elbow
Only in the neck
29
Do your hands feel clumsy? Difficulty with buttons or writing?
YESNO
30
Are you losing your balance?
YESNO
31
Have you had any falls in the last 7 days?
YESNO
32
Do you get pain in the groin?
YESNO
33
Do you find it difficult to put on socks or shoes?
YESNO
34
Do you use a walker or cane?
YESNO
35
Do you smoke?
YESNO
36
Do you have diabetes?
YESNO
37
Do you have any heart problems (e.g. heart attack)
YESNO
38
Do you have depression or anxiety?
YESNO
39
Do you have any previous history of cancer?
YESNO
40
Have you had any previous spine surgery?
YESNO
41
Do you take any blood thinner medications?
YESNO
Should be Empty: