Spine Questionnaire

What makes your symptoms better?

What makes your symptoms worse?

What medication(s) are you currently taking for the pain?

Over the last month, how often have you taken medication for the pain?

Describe any part of your body that is numb

Describe any party of your body that is weak

What does your problem limit you from doing

How far can you walk comfortably?

Please check and list the approximate date of any diagnostic test you have had performed on your spine

Latest date of X-Ray *

Latest date of MRI *

Latest date of EMG *

Latest date of CT scan or Myleogram *

Latest date of bone scan *

Latest date of Discogram *

Please specify about the diagnostic test *

What treatments have you tried?

Treatment

Was it Helpful?

Number of Treatments

Date of most recent
Treatment

Physical Therapy

PT – helpful

pt #

pt date

Acupuncture

ap – helpful

ap #

ap date

Chiropractor

chi – helpful

chi #

chi date

Injections

inj – helpful

inj #

inj date

Massage

mas – helpful

mas #

mas date

Have you had surgery on your spine?

Yes
No

Date *

Surgeon *

Surgical Procedure *

Do you have any medical problems? (Please check all relevant problems)

Cancer Type *

Please specify any other medical problems *

Please check and list the approximate dates, if any, that you have had any of the following surgeries

Heart Surgery Date *

Lung Surgery Date *

Appendectomy Date *

Hernia Repair Date *

Please specify any other surgeries *

Please check and describe if you have any health problems with any of the following areas:

Fever or Weight Loss – Please describe further *

Eye, Ear, Nose or Throat – Please describe further *

Heart Problem – Please describe further *

Breathing / Lung Problems – Please describe further *

Stomach / Intestinal Problems – Please describe further *

Kidney / Liver Problems – Please describe further *

Skin Conditions – Please describe further *

Urinary Problems – Please describe further *

Please describe applicable)

Infections – Please describe further *

Bleeding Problems – Please describe further *

Neurological Problems – Please describe further *

Psychiatric Problems – Please describe further *

Please list any medications to which you have an allergy to and the reaction the medication causes:

Medication

Reaction

Please list ALL medications that you are currently taking, the dosage and the reason for taking each medication:

Medication

Dosage (amount & frequency)

Reason

Please check and list the relationship if a family member has problems with the following:

Cancer – affected family member *

Diabetes – affected family member *

Heart Disease – affected family member *

Kidney Problems – affected family member *

Hypertension – affected family member

Stroke – affected family member *

Arthritis – affected family member *

Scoliosis – affected family member *

Other – Please describe *

Do you smoke?

No, I have never smoked
Yes, I have smoked
No, I quit

For how many years have you been smoking? *

When did you quit smoking? *

How many years did you smoke before quitting? *

How many cigarettes do (or did) you smoke on most days? *

How much alcohol do you drink on an average week?

Have you retained a solicitor because of your spine problem?

No
Yes, settled lawsuit
Yes, pending lawsuit
Yes, case status unknown

Please check the following that best describes your current employment:

Welcome to the Spine & Orthopaedic Centre.
Please take a few minutes to complete the attached questionnaire.
Having this information completed gives us the best chance to accurately diagnose and treat your problems.

Out of 100%, how much of your pain is located centrally in your back or neck and how much radiates out to your legs and arms?

What treatments have you tried?

Treatment

Was it Helpful?

Number of Treatments

Date of most recent
Treatment

Physical Therapy

Acupuncture

Chiropractor

Injections

Massage

Please list any medications to which you have an allergy to and the reaction the medication causes:

Please list ALL medications that you are currently taking, the dosage and the reason for taking each medication:

Request for an appointment

Spine & Orthopaedic Centre

Spine Questionnaire

Welcome to the Spine & Orthopaedic Centre. Please take a few minutes to complete the attached questionnaire. Having this information completed gives us the best chance to accurately diagnose and treat your problems.

Out of 100%, how much of your pain is located centrally in your back or neck and how much radiates out to your legs and arms?

What treatments have you tried?

Treatment

Was it Helpful?

Number of Treatments

Date of most recent Treatment

Physical Therapy

Acupuncture

Chiropractor

Injections

Massage

Please list any medications to which you have an allergy to and the reaction the medication causes:

Please list ALL medications that you are currently taking, the dosage and the reason for taking each medication:

Request for an appointment

Spine & Orthopaedic Centre

Welcome to the Spine & Orthopaedic Centre.
Please take a few minutes to complete the attached questionnaire.
Having this information completed gives us the best chance to accurately diagnose and treat your problems.

Date of most recent
Treatment