PATIENT REGISTRATION Part 2

Title *

First Name *

Middle Name

Last Name *

Email Address *

CHIEF COMPLAINT

Any other complaints

If more than one area, which is the worst?

How long have you had this problem? *

Did your symptoms follow an injury? *

YesNo

If YES, did the injury occur

At workAuto accidentOther

Please specify

Please describe what happened

PREVIOUS TREATMENT

REVIEW OF SYSTEMS

Tick all conditions you are currently experiencing.

If pregnant, date of last period

PAST SURGICAL HISTORYPlease include YEAR, OPERATION, PLACE HOSPITALISED

Have you ever had previous SPINAL SURGERY? *

YesNo

If so, what were your symptoms before the surgery? Please describe

Did your symptoms improve after surgery?

YesNo

If YES how long afterwards?

Did you get worse after surgery?

YesNo

If YES, please explain

Were you released back to work after surgery?

YesNo

If YES when?

Allergies *Include NAME OF MEDICINE/SUBSTANCE, TYPE OF REACTION and DATE (if known). If no allergies, please write NONE

Medicines *List all medicines that you take, including the doses and how often you take them. Include vitamins & non-prescription medicine. If none, write NONE.

I need more space for Allergies and/or Medications

PREVIOUS INVESTIGATIONS & TREATMENT

Please list dates of previous radiology studies you have had for your current spinal problem

MRI

CT Scan

X-Rays

Bone Mineral Density Scan

EMG / Nerve Conduction Studies

Bone Scan

FAMILY HISTORY: Does anyone in your family apart from you suffer from any of the following conditions? Please tick relevant ones.

Please provide details

SOCIAL HISTORY

Number of Children

Ages of Children

Who lives at home with you? *

Primary Occupation *Or previous if not working / retired

How long have you worked at your present job?

Approximate number of hours per week

If not working, last date worked

Spouse / partner's occupation

Do you currently use tobacco? *

YesNo

If YES, type amount per day

Years smoking

Have you ever used tobacco? *

YesNo

Include past smoking even if currently not smoking

Amount of alcohol consumed in a typical week *Write zero if non-drinker

Recreational Drug Use? *

YesNo

Do you participate in any regular exercise? *

YesNo

Please describe

EQ-5D

By placing a checkmark in one box in each group below, please indicate which statements best describe your own health state TODAY.

Mobility *

I have no problems in walking aboutI have slight problems in walking aboutI have moderate problems in walking aboutI have severe problems in walking aboutI am unable to walk about

Self-Care *

I have no problems washing or dressing myselfI have slight problems washing or dressing myselfI have moderate problems washing or dressing myselfI have severe problems washing or dressing myselfI am unable to wash or dress myself

Usual Activities (e.g. work, study, housework, family or leisure activities) *

I have no problems with performing my usual activitiesI have some problems with performing my usual activitiesI have moderate problems with performing my usual activitiesI have severe problems with performing my usual activitiesI am unable to perform my usual activities

Pain / Discomfort *

I have no pain or discomfortI have slight pain or discomfortI have moderate pain or discomfortI have severe pain or discomfortI have extreme pain or discomfort

Anxiety / Depression *

I am not anxious or depressedI am slightly anxious or depressedI am moderately anxious or depressedI am severely anxious or depressedI am extremely anxious or depressed

If nothing appears to happen after you click the SUBMIT button, please scroll up to check for any required fields that have been missed. They will be highlighted in RED.

NSW Spine Specialists
1300 975 800
www.nswspinespecialists.com.au