Woodlands | Houston Spine Center: Patient Forms

PATIENT FORMS

Statement

We believe in treating all spinal patients as if they were our own family members. A non-surgical approach is always the first line of treatment. If surgical care is what you require we believe in delivering the most minimally invasive options and cutting edge treatments available today. No patient wants to have more surgery than is necessary and we believe in achieving our goals with the least trauma, the shortest hospital stay in the most safe and effective manner.

Please download, complete and bring in the following three forms for your visit :

Completed forms could also be E-mailed as attachments to:
info@surgicalspinesolutions.com
or faxed to: (832) 553-3211

Spine Center: New Patient Questionnaire

Name*

Phone Number

###

####

Email*

Date

YYYY

Age*

What do you expect to gain from today's visit?

Please indicate on a scale of 0 to 10 how much
pain you have in each area

A description of the section goes here.

Low Back

Legs

Middle Back

Neck

Arms

Did you have an injury

Exact Date of Injury

YYYY

Details of Injury

Do you have a lawsuit or worker's compensation
case pending?

How long have you had the pain?

What have you found that makes the pain worse or
better?

Is your pain worse with coughing or sneezing

Is your pain worse at night?

Does it wake you at night?

Have you had any fever, chills or night sweats?

Have you had any recent unplanned or sudden weight
loss?

Has there been any disturbance of bowel or
bladder?

Is your leg pain worse with walking?

How far can you walk?

Is your leg pain relieved by resting?

Does your leg pain get better if you lean forward?

Sitting makes your pain?

Standing makes your pain:

Lying down makes your pain:

Physical activity makes your pain:

Which, if any, of the treatments below have you
had so far?

A description of the section goes here.

Physical therapy?

Treatment dates & duration:

Chiropractic?

Treatment dates & duration:

Spinal Steroid Injections?

Did it make you feel better or worse

Treatment dates, and what type of injection?

Pain medications?

Did they help?

What medications?

What tests have you had for this condition thus
far?

MRI

CT Scan

Myelogram

Bone scan

Blood tests

List the dates for conditions above or types for
blood tests

Have you had surgery on your spine?

If so what type(s), what date(s) and name of
surgeon?

Past Medical History

A description of the section goes here.

Have you been diagnosed with any of the following
conditions?

Hypertension

Heart rhythm disturbance

Stroke

Diabetes

Malignant hyperthermia

Pulmonary Disease

Leg Blood Clot

Colon Problems

Blood clotting disorder

Hepatitis

Depression

Asthma

Vascular Disease

Heart Failure

Epilepsy

Poor Circulation

Osteoporosis

Latex allergy

Bacteraemia

Swallowing difficulty

Anemia

HIV or AIDS

Anxiety

Multiple Sclerosis

Cancer

Difficult anesthesia

Lung Blood Clot

Serious Infection

Liver Disease

Immune disorder

Nickel allergy

Psychosis

Please list any other conditions not mentioned
above

Past Surgical History:

Family History

A description of the section goes here.

Is there a family history of the following
conditions?

Heart Disease

Cancer

Blood disorder

Stroke

Diabetes

Hypertension

Scoliosis

Anesthetic problems

Epilepsy

Please list any other conditions not mentioned
above

Social History

A description of the section goes here.

Which applies to you

Married

Single

Divorced

Widowed

Working full time

Working part time

Retired

Unemployed

Student

Occupation

Does work involve lifting?

Do you have children?

If yes, what ages?

Smoker?

How many a day?

Smoked for how many years total?

Drinker?

Drugs/Narcotics

Psychiatric illness of any kind?

If yes, please give details

Medications:

A description of the section goes here.

Please list medications, doses and how often you
take them.

Are you taking any non-prescription medication at
all? eg.Vitamins, herbs, health supplement. If so,
please list them as these may sometimes affect you
during any surgery