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  • History of Treatment

  • Have you had any Testing done for your current symptoms*
  • Did You have a*
  • What type of treatments have you had for your condition?*
  • Did Physical Therapy help?*

  • Was the procedure done under fluoroscope or x-ray machine with you lying face down on a table?*
  • Did the Epidural Steriod Injection help?*

  • Was the procedure done under fluoroscope or x-ray machine with you lying face down on a table?*
  • Was the procedure done under fluoroscope or x-ray machine with you lying face down on a table?*
  • Location of Epidural Steriod Injection*
  • Location of Facet Rhizotomy.*
  • Did the Facet Injection help?*

  • Did the Facet Injection help?*

  • Past Surgical History

  • Have you had any neurological surgeries before?*
  • Neurological Surgeries
  • Have you had any other non neurological surgery before?*
  • Other Surgery
  • Which hand was the Carpal Tunnel Release:*
  • Which hand was the Ulnar Nerve Decompression:*
  • Location of Facet Injections*
  • Did the Chiropracter help?*

  • Please mark the surgeries you have had before.

  • Head and Neck Surgery:
  • Breast Surgery:
  • Cardiovascular Procedure/Surgery
  • Gynecology/Urology
  • Abdominal/Colon Surgery:
  • Cataract Surgery*
  • Carotid Repair*
  • Was the Partial colectomy for:*

  • Which knee did you have surgery on:*

  • Past Medical History

  • Please check any of the below illness which you have or have had in the past.  Use the spaces below this table to describe any details of checked illness or other unlisted conditions and illnesses including when it was diagnosed, how it was/is treated.

  • General
  • Cardiovascular
  • Neurological
  • Musculoskeltal
  • Genito-Urnary
  • Psychiatric
  • Infection
  • Hematological
  • Repiratory
  • Eye
  • Gastrointestinal
  • Do you have a Cardiologist?*
  • Any additional strokes?*
  • What type of Cancer?*
  • Do you experience heavy snoring, daytime fatigue or periods of apnea during sleep?*
  • Do you have difficulty walking more than one block due to shortness of breathe?*
  • Have you had any recent acute illness,colds,coughs,asthma attacks etc?*
  • Have any direct family members have any problem with anesthesia?*
  • Have any direct family members have any know inherited disorders that affect anesthesia care such as Pseudo-cholinesterase deficiencey?*
  • Do you have an implanted Defibrillator or pacemaker?*
  • Any foreign objects( includes gun or shrapnel fragments), in your body or your eyes?*
  • Are you claustrophic or had any problems with failed previous attempts in a closed MRI machine?*
  • Do you smoke?*
  • Do you drink?*
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  • Should be Empty: