Spine Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Name *FirstLastEmail *Phone *WeightHeightA. chief complaint (check those that apply): Neck pain Back pain ArmLegSexMaleFemaleHow long has the pain (or your problem) been present?What started the pain/ problem?What percent of your pain is neck and what % is arm pain? I have all neck pain I have all arm pain I have _________% arm pain, these should =100% I have _________% neck pain, these should =100%For arm pain:LEFTRIGHTRaising the arm:Improves the painWorsens the pain No changeMoving the neck:Improves the painWorsens the pain No changeThere is: WeaknessNO weakness in the arms or handsThere is: Numbness in the hands or armsNo numbnessDo you have difficulty picking up small objects like coins or buttoning your buttons?YesNoDo you have problems with balance, or trip frequently:YesNoWhat percent of your pain is back pain (from mid-back to buttocks)?____% What percent of your pain goes down each leg?LEFTRIGHTDo you have pain that “shoots” or goes below your knees?YesNoThere is weakness of my:LEFTRIGHTLEFT: ThighCalfAnkleFootToeNo weakness RIGHT:ThighCalfAnkleFootToeNo weakness There is numbness of my:LEFTRIGHTLEFT: ThighCalfAnkleFootToeNo weakness RIGHT: ThighCalfAnkleFootToeNo weakness The worst position for my pain is: SittingStanding Walking How many minutes can you stand in one place without pain?0-1515-3030-60 60+How many blocks can you walk without pain?0-34-71 mile2 miles or more Lying down:Eases my painMake it worseNo effectBending forward:Eases my painMake it worseNo effectCoughing or sneezing:Eases my painMake it worseNo effectThere is: No loss of bowel or bladder controlLoss of control since______describe ________________. I have:Not missed any work because of this problemHave missedTREATMENTS SO FAR INCLUDE:Physical therapyExercise programMassage or UltrasoundChiropracticHomeopathic or AcupunctureBracesAnti-inflammatory medicationsNarcotic medicationsSteroid injectionsHow long did they relieve the pain for?Are there any other non surgical treatments left that you have tried?Previous doctors seen for this problem:Diagnostic Tests done to evaluate this problem:X-raysCT ScanMyelogramMRIEMG’sBone ScanYour Medical History: (check all that apply)None applyHeart AttackHeart FailureHigh Blood Pressure OsteoarthritisRheumatoid Arthritis Ankylosing SpondylitisGoutOsteoporosisDiabetesStrokeSeizuresMental IllnessKidney StonesKidney FailureCancerAlcoholismLung DiseaseAIDSTuberculosisAsthmaBlood Clot in LegBlood Clot in LungStomach UlcersLiver TroubleHepatitisThyroid Trouble Bleeding Disorders AnemiaSerious Injuries (explain)Surgical History (including spine):Medications you take (list dose and frequency):Medications that you have tried for your problem:Medication allergies:Work status: HomemakerWorkingRetiredDisabledOn leave Occupation (current or most recent):Date last worked Marital status: SingleMarriedDivorcedWidowedCohabitingTobacco use:NeverCigarChewPipeAlcohol:NeverRareSocialDrink frequently (more than twice week)Drug use: NeverIn the pastCurrentlyIV drugsBecause of this problem do you have, or plan to have:LawsuitWorkman’s compensation claimUnsureNoneFamily Medical History: (check all that apply):None applyHeart AttackHeart FailureHigh Blood Pressure OsteoarthritisRheumatoid Arthritis Ankylosing SpondylitisGoutOsteoporosisDiabetesStrokeSeizuresMental IllnessKidney StonesKidney FailureCancerAlcoholismLung DiseaseAIDSTuberculosisAsthmaBlood Clot in LegBlood Clot in LungStomach UlcersLiver TroubleHepatitisThyroid Trouble Bleeding Disorders Anemia Review of Systems: (check all that apply): None applyReading Glasses Change of VisionLoss of Hearing Ear pain HoarsenessNosebleedsDifficult Swallowing Morning Cough Shortness of BreathFever or Chills Heart or Chest PainAbnormal HeartbeatSwollen AnklesCalf Cramps w/WalkingPoor AppetiteToothacheGum TroubleNausea or VomitingStomach PainUlcersFrequent Belching Frequent DiarrheaFrequent ConstipationHemorrhoidsFrequent UrinationBurning on UrinationDifficulty Starting UrinationGet up more than once every night to urinate Frequent HeadachesBlackoutsSeizuresFrequent RashHot or Cold SpellsRecent Weight Change Nervous ExhaustionOther:PhoneSubmit