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 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *WeightHeightA. chief complaint (check those that apply): Neck painBack painArmLegSexMaleFemaleHow 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 painI 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 painNo changeMoving the neck:Improves the painWorsens the painNo 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 weaknessRIGHT:ThighCalfAnkleFootToeNo weaknessThere is numbness of my:LEFTRIGHTLEFT: ThighCalfAnkleFootToeNo weaknessRIGHT: ThighCalfAnkleFootToeNo weaknessThe worst position for my pain is: SittingStandingWalkingHow many minutes can you stand in one place without pain?0-1515-3030-6060+How many blocks can you walk without pain?0-34-71 mile2 miles or moreLying 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 PressureOsteoarthritisRheumatoid ArthritisAnkylosing SpondylitisGoutOsteoporosisDiabetesStrokeSeizuresMental IllnessKidney StonesKidney FailureCancerAlcoholismLung DiseaseAIDSTuberculosisAsthmaBlood Clot in LegBlood Clot in LungStomach UlcersLiver TroubleHepatitisThyroid TroubleBleeding DisordersAnemiaSerious 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 PressureOsteoarthritisRheumatoid ArthritisAnkylosing SpondylitisGoutOsteoporosisDiabetesStrokeSeizuresMental IllnessKidney StonesKidney FailureCancerAlcoholismLung DiseaseAIDSTuberculosisAsthmaBlood Clot in LegBlood Clot in LungStomach UlcersLiver TroubleHepatitisThyroid TroubleBleeding DisordersAnemia Review of Systems: (check all that apply): None applyReading GlassesChange of VisionLoss of HearingEar painHoarsenessNosebleedsDifficult SwallowingMorning CoughShortness of BreathFever or ChillsHeart or Chest PainAbnormal HeartbeatSwollen AnklesCalf Cramps w/WalkingPoor AppetiteToothacheGum TroubleNausea or VomitingStomach PainUlcersFrequent BelchingFrequent DiarrheaFrequent ConstipationHemorrhoidsFrequent UrinationBurning on UrinationDifficulty Starting UrinationGet up more than once every night to urinateFrequent HeadachesBlackoutsSeizuresFrequent RashHot or Cold SpellsRecent Weight ChangeNervous ExhaustionOther:CommentSubmit