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MEDICAL QUESTIONNAIRE

MEDICAL QUESTIONNAIRE

FLORIDA SPINE AND SPORTS SPECIALISTS MEDICAL QUESTIONNAIRE
Kalman D. Blumberg MD, Kevin D. Cairns MD, George L. Caldwell, MD, Harold L. Dalton DO, William Porter McRoberts, MD, Giuseppe G. Paese DO

Name*
First Last
Date*
MM slash DD slash YYYY
Age:*
Sex:*
Hand*
- Right-Handed
- Left-Handed
1. Are your current symptoms a result of an injury?
- Yes
If yes please specify:
2. Have you had similar back/neck problems in the past? Yes; when did symptoms begin:
MM slash DD slash YYYY
Similar back/neck problems in the past?
- No
3. Approximately when did this episode of back, leg, or arm pain start?*
4. What were you doing when your symptoms started?
- Unsure
- Sitting
- Bending
- Lifting
- Walking
- Sports
- Accident
Other
5. Please explain where your pain first started:
- Lower Back
- Upper Back
- Neck
- Lower back & one leg
- Lower back & both legs
- Leg(s) only
- Neck & one arm
- Neck & both arms
- Arm(s) only
Other
6. How has your pain changed since it started?
- Improving
- No change
- Worse in one or both arms
- Worse in one or both legs
- Worse in back
7. Which activities increase your symptoms/pain?
- Standing
- Sitting
- Lying
- Walking
- Twisting
- Driving
- Reaching
Other
8. What relieves your symptoms?
- Standing
- Sitting
- Lying
- Walking
- Twisting
- Driving
- Reaching
Other
9. Have you completed any of the following treatments/evaluations of current problem? (Please specify)
Physical Therapy
- Yes
Therapy start date:
Sessions completed:
Facility where completed:
Injections
- Yes
Type of injection:
Date of treatment:
Treating physician:
Relief?
- Yes
If yes, length of time:
Ice/Heat Therapy
- Yes
Traction
- Yes
Back Support
- Yes
TENS Unit
- Yes
Chiropractic Care
- Yes
Acupuncture
- Yes
Home or Water Exercises
- Yes
EMG/Nerve Conduction Study
- Yes
Imaging including x-ray(s), MRI(s), CT scan(s), etc.
- Yes
ALLERGIES
List any medications to which you are allergic:
CURRENT MEDICATIONS
List all medications you are currently taking:
PAST MEDICAL HISTORY
Do you have a history of any of the following?
Cancer:
- Yes
Type:
Treatment:
Diabetes
- Yes
High blood pressure
- Yes
Heart disease
- Yes
Mitral valve prolapse
- Yes
Phlebitis
- Yes
Liver disease
- Yes
Peptic ulcers
- Yes
Anemia
- Yes
HIV or AIDS
- Yes
Kidney disease
- Yes
Asthma
- Yes
Epilepsy
- Yes
Glaucoma
- Yes
Thyroid disease
- Yes
Polio
- Yes
Arthritis
- Yes
Blood transfusions
- Yes
Are you currently experiencing any of the following symptoms (Check all that apply)
Fever
- Yes
Heat/cold intolerance
- Yes
Fatigue
- Yes
Suicidal thoughts
- Yes
Double vision
- Yes
Seizures
- Yes
Hearing problems
- Yes
Dizziness
- Yes
Shortness of breath
- Yes
Chest Pain
- Yes
Blood in urine
- Yes
Varicose veins
- Yes
Vomiting
- Yes
Ankle swelling
- Yes
Memory Loss
- Yes
Abdominal pain
- Yes
New cough/wheeze
- Yes
Bladder infection
- Yes
Skin changes/rashes
- Yes
IV drug abuse
- Yes
Sexual dysfunction
- Yes
Migraine headaches
- Yes
Frequent bruising
- Yes
Insomnia
- Yes
Vertigo
- Yes
Anxiety requiring medication
- Yes
Swollen glands
- Yes
Have you ever had major physical trauma?
- Yes
What?
Have you been hospitalized in the last year?
- Yes
Why?
Do you have difficulty sleeping?
- Yes
Have you lost control of your bowel or bladder?
- Yes
How much weight can you comfortable lift?
FAMILY MEDICAL HISTORY
Do you have a family history of medical problems?
- Adopted
- Yes
Yes: please specify:
Do you suffer from headaches?
- Yes
Do you have difficulty sleeping?
- Yes
How much weight can you comfortable lift?
SURGICAL HISTORY
List past surgeries (include dates):
Type:
Type:
Surgeon:
Surgeon:
Hospital:
Hospital:
Date:
Date:
SOCIAL HISTORY:
Occupation:
- Active
- Retired
Alcohol Use:
- None
- Rare
- Social
- Frequent
Smoking History:
- Nonsmoker
- Current smoker:
¼ pack per day
½ pack per day
packs per day
Previous smoker (cessation date):
Are you?
- single
- married
- widowed
- divorced
How many children do you have?
What is your highest education level?
How many stairs to enter your home?
How many people live in your home?
What are your hobbies?
WORK/MOTOR VEHICLE INJURY
Is your injury work related?
- Yes
If yes: When did the injury occur?
Have you missed work as a result of this injury?
- Yes
Do you have work restrictions?
- Yes
Is your injury due to a motor vehicle accident?
- Yes
If yes: When did the accident occur?
Were you rushed to the emergency room via ambulance?
- Yes
Which hospital?
Were you wearing a seat belt at time of impact?
- Yes
- Not applicable
Did you hit your head?
- Yes
Did you lose consciousness?
- Yes
Approximately how fast was the other car(s) traveling?
Approximately how fast was your car traveling?
Were you the driver, front or rear passenger, or pedestrian at time of incident?
Were you hit from the back, front, driver, or passenger side?

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