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 ALLERGIESList any medications to which you are allergic: CURRENT MEDICATIONSList all medications you are currently taking: PAST MEDICAL HISTORYDo 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 HISTORYDo 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 HISTORYList 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 INJURYIs 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?