BASELINE QUESTIONNAIRE

 

 
Name:    _______________       _______________        _______     Age:______

                                       Last                                               First                      Middle Initial

 

Date:      ______/______200____     Height:  ____ft____in   Weight:  _______lbs

 

Referring M.D. __________________                                                                      Primary Treating M.D. (if  different)                       

Will you be seeing the referring doctor in follow up?       Yes     No

                                                                                             

1.       Are we seeing you for neck (arm) pain, mid back or low back (leg) pain?  __________________________

                                                                                        (circle one)

 

2.       Who is the primary physician that is treating you for your current spine condition?                                          

 

3.       When did you first start having problems with your back / neck?                             /            /            

                                                                                                                                                                month  / day /  year

4.       Please check all that apply for this injury:

 

[]    This is my first episode of back/neck pain. (circle one)

[]    I have had more than one episode of back/neck pain.  In between episodes I don’t have much pain.

[]    I have had pain continuously ever since it first began.  Sometimes it is worse than others, but it is always there.

[]    I have had constant, severe pain ever since it first began.

 

3.       Are your symptoms related to an injury (including repetitive strain injuries)?

 

            []    NO

[]    YES, answer the following: 

a.       The date of the injury was _______________(month, day, year)

b.       The injury was a (choose one):

            ()  Motor Vehicle Injury

      ()  Lifting Injury

      ()  Falling Injury

                              ()  Repetitive strain

      ()  Other

c.   The injury was (choose one):

                              ()  Work related

      ()  Not work related

d.       Please describe your injury in as much detail as possible:                                                             

                                                                                                                                                     

                                                                                                                                                     

               

4.   Which of the following types of physicians have you seen for your low back pain?

(Please check all that apply)

 

            []  Primary Care (including nurse practitioner)           []  Physiatrist                         [] Other                              

            []  Orthopedic surgeon                                             []  Chiropractor

            []  Neurosurgeon                                                     []  Pain Management

            []  Neurologist                                                         []  Doctor of Osteopath (D.O.)

 

5.   Which of the following therapies have you tried for your back or neck pain?   (Please check all that apply)

 

            []    Pain pills (e.g., Tylenol w/ Codeine, Darvocet, etc.)   []    Chiropractic/Osteopathic Manipulations

            []    Antidepressants (e.g., Elavil, Prozac, etc.)                 []    Physical Therapy

            []    Muscle Relaxants (e.g., Flexeril, etc.)                       []    Injections, (Trigger Point, epidural, facet,

      []    Anti-inflammatories (e.g., Motrin, Advil, Alleve)              botox, etc.) __________________________

      []    Holistic / Herbal                                                      []    Other                                                         

            []    Acupuncture

 

 

 

6.   Have you had surgery for your current spine injury?

            []  NO

            []  YES, I have had _____ # of surgeries relating to my current episode.

(complete the following relating to your three most recent surgeries):

 

Surgery Number

(Most recent first)

Date

Surgery Type / Level

(Please provide details.)

Change in condition after Surgery.

 (circle one)

#1

 

 

   Same    Better    Worse

for _________  months.

#2

 

 

 

   Same    Better    Worse

for _________  months.

#3

 

 

 

   Same    Better    Worse

for _________  months.

 

 

7.        Have you had any of the following diagnostics tests for your current spine pain?  (please check all that apply)

 

                                                        Approx date                                 Results (If Known)

            []    MRI Scan                                                                                                               

            []    CT Scan                                                                                                                 

            []    Myelogram                                                                                                             

            []    Discogram                                                                                                              

            []    EMG Test                                                                                                               

            []    Other                                                                                                                      

 

8.       What is your understanding of the current treatment plan?                                                          

 

      9.   Have you ever had episodes of pain in other parts of your spine?

            []    NO   (IF NO, GO TO QUESTION 10)

            []    YES How many? __________(IF YES, answer the questions in the box below then go to question 10)

 

A.     Have you had surgery on other parts of your spine other then what we are treating you for?

            ()  No, Describe the treatment you received:______________________

            ()  Yes, Type of surgery: _____________________________________

B.     Are you having problems with other parts of your spine other than what we are treating you for?

            ()  No

            ()  Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

Questions 10 – 20 relate to your current episode of symptoms

 

10.   Please mark the location(s) of your pain on the body outlines using the symbols below.

 

OOO Pins &

OOO Needles

/ / / / / /    Stabbing

/ / / / / /

XXX Burning

XXX

= = = Numbness  

= = =

AAAA Aching

AAAA & Cramping

+ + +Other Sensations

+ + +


 

 

Which hurts you more your legs or back?                      OR                          Which hurts you more your arm or neck?      

()     legs hurt much more                                                                                    () arms hurt much more

()     legs hurt somewhat more                                                                            () arms hurt somewhat more                              

()     legs and back hurt about the same                                                           () arms and neck hurt about the same              

()     back hurts somewhat more                                                                         () neck hurts somewhat more                            

().    back hurts much more                                                                                 () neck hurts much more

       

If you have both leg and back pain:                                 OR                          If you have both arm and arm pain

                                                                                                                                               

My back is ­­­­­­­­                               % of my pain      should total                        My neck is ________% of my pain       should total

My legs are                               % of my pain            100%                               My arms are ________% of my pain          100%

 

 

11.  Please place a mark on the line at the point that represents your level of pain TODAY.

 

 

                  No  |------|------|------|------|------|------|------|------|------|------|  Worst Possible

                  Pain                                                                                                                   Pain

 

 

12.  Please place a mark on the line at the point that represents your level of pain IN THE LAST WEEK.

 

                  No  |------|------|------|------|------|------|------|------|------|------|  Worst Possible

                  Pain                                                                                                                   Pain

 

13.  Are your symptoms: (please check one)

            ()    always there

            ()    sometimes shut off

 

14.  Have your symptoms been:

            []    improving

            []    unchanging

            []    worsening

 

15.  Note the effect of the following activities on your symptoms.  Check one box on each line and fill in the amount of time you can tolerate each activity before changing activity:

 

 

 

 

 

 

 

Activity

 

CHECK ONE

BOX ON

EACH LINE

 

 

Tolerance-Time in minutes

 

(fill in each line)

 

The Activity has no effect  on my symptoms

 

I Feel

Better

With…

 

I Feel

Worse

With…

 

 

Bending

 

 

 

 

Not Applicable

 

 

Sitting

 

 

 

 

                Min.

 

 

Standing

 

 

 

 

                Min.

 

 

Walking

 

 

 

 

                Min.

 

 

Lying down

 

 

 

 

                Min.

 

 

Coughing or Straining

 

 

 

 

Not Applicable

 

 

Reading

 

 

 

 

                Min.

 

 

Driving

 

 

 

 

                Min.

 

 

Working on Computer/Desk

 

 

 

 

 

                Min.

 

 

 

 

16.  Pain medication in the last week: (circle one)

 

None

Occasional Non Narcotic

Daily Non Narcotic

Occasional Narcotic

Daily Narcotic

1

2

3

4

5

 

 

17.  During the past week, how much did pain interfere with your normal work

      (including both work outside the home and housework)? (please circle one)

 

Not at all

A little bit

Moderately

Quite a bit

Extremely

1

2

3

4

5

 

 

18.  If you had to spend the rest of your life with your present pain condition, how would you feel about it?

      (please circle one)

 

Very satisfied

Somewhat satisfied

Neutral

Somewhat dissatisfied

Very dissatisfied

1

2

3

4

5

 

 

19.  During the past 4 weeks, about how many days did you cut down on the things you usually do for more than half the day because of your pain? (please circle one)

 

0-5 (days)

6-11 (days)

12-17 (days)

18-23 (days)

24-28 (days)

1

2

3

4

5

 

 

20.   During the past 4 weeks how many days did your pain keep you from going to work or

      school? (please circle one)

 

0-5 (days)

6-11 (days)

12-17 (days)

18-23 (days)

24-28 (days)

1

2

3

4

5

 

 

21.  During the past week, how bothersome have each of the following symptoms been? (please circle one)

 

Circle Back or neck

And Leg or Arm

Not at all bothersome

Slightly bothersome

Moderately bothersome

Very  bothersome

Extremely bothersome

Back pain/ Neck

1

2

3

4

5

Leg pain / Arm

1

2

3

4

5

             

 

Staff use only:______

 

 

Questions 22 – 27 relate to your general health

 

22.  Do you have a history or have you been told at any time you have/had any of the following:

 

            []    Vascular disease (including hardening of the arteries or atherosclersois, angina, or a history of a heart

                  attack or congestive heart failure)

            []    Cancer                                                                   []    Anesthesia Problems

            []    History of or prone to Infection                                []    Fainting Spells

            []    Rheumatoid arthritis                                                 []    NONE       

            []    Unexplained weight loss                                                

            []    Fever or chills                                                              

            []    Swollen joints                                                               

            []    Skin disease                                                                 

            []    Eye irritation                                                                

 

23.  Have you been diagnosed with any of the following conditions? (Please check all that apply)

 

            []    Heart Disease                                                         []    Chronic Lung Disease

            []    High Blood Pressure                                                []    Asthma      

            []    Bleeding disorders                                                   []    Bronchitis

            []    Liver Disease                                                          []    Emphysema

            []    Kidney Disease                                                       []    Migraines   

            []    Diabetes mellitus                                                     []    Prior Anesthetic Problems  

            []    Thyroid                                                                   []    Other:                                

            []    Ulcer or Gastrointestinal Bleeding                             []    NONE                                                       

            []    Neurologic Disease (including stroke, epilepsy, transient ischemic attacks)

           

24.  List ALL prescribed AND over the counter medications or herbs you are currently taking and daily amount:

                                              

                                                                                                                                                        

 

                                                                                                                                                        

 

                                                                                                                                                        

 

                                                                                                                                                        

 

25.  Please list any allergies you have to medications, including allergies to antibiotics, local anesthetics, x-ray contrast “dye”, or latex materials:

                                                                                                                                                                       

 

26.   Please list any surgery you have had which is not related to your current symptoms including but not limited to

      transplants, implants, stents, pacemaker, hardware, prosthesis, shoulder, knee, elbow, hand repair, etc.:

     

                                                                                                                                                                        

 

                                                                                                                                                                        

 

27.  Have you had any of the following since your current symptoms started? (check all that apply)

 

            []    episodes of sadness                                                             []  fever or chills

            []    depression                                                                           []  unexplained weight loss

            []    anxiety                                                                                []  swollen joints

            []    crying spells                                                                        []  skin disease

[]    difficulty sleeping                                                                 []  eye irritation

 

 

Questions 28 –43 relate to your employment status and living situation

 

28.  If any of the following describe you, please check and then proceed to question 31

      (check one)

            ()    Full-time Homemaker

            ()    Full-time Student

            ()    Retired (Not due to health)

            ()    Permanently disabled due to a health problem no related to my symptoms

            ()    None of the above

           

29.  What is your primary occupation?  If you are not working now, indicate your primary occupation when you were working. (Please be as specific as possible)

 

            Occupation:________________________________________________________

 

            Current Employer:___________________________________________________

 

30.  Are you currently working?

[]  YES (choose the  ONE answer that best describes your current work situation)

                  ()    I have the exact same job since I started having symptoms

                  ()    I have the same job, but it was modified or the hours were reduced because of my symptoms

                  ()    I have changed jobs because of my symptoms

                  ()    I have changed jobs, but for reasons unrelated to my symptoms

[]  NO (answer the following)

                  a.   I have been off work for _________year(s)________month(s)_________week(s)

                  b.   Check which of the following describes your current work status (please check one) 

                              ()    I am unable to work because of my symptoms

                              ()    I am able to work but I am unemployed

c.       Which of the following best describes your plans for future employment

(check one)?

                                    ()  I intend to return to my same job

                        ()  I plan to return to my occupation but with restricted duty

                        ()  I plan to find a different occupation

                        ()  I don’t intend to return to work

 

 

31.  Have you ever had to miss work because of your back pain in the past?

      []    NO

      []    YES.  (answer the following)

A.  How much work did you miss as a result of your worst prior episode ?             

B.   Did you return to full function before your current episode ?   []  Yes   []  No

 

32.  Have you ever had to miss work because of neck pain in the past ?

      []    NO

      []    YES. (answer the following)

A. How much work did you miss as a result of your worst prior episode?               

B.  Did you return to full function before your current episode?    []  Yes   []  No

           

33.  Have you ever had to miss work because of other medical conditions in the past?

      []    NO

      []    YES,  Describe:                                                                                                                                   

                                                                                                                                                                       

                                                                                                                                                                       

 

 

34.  Have you been told your condition is permanent and stationary (workers comp)?

            ()    NO

            ()    YES

 

35.  Have you been given a disability rating? 

            ()    NO

            ()    YES, what percent?  _______%

 

36.  What is your current living situation?

            ()    Married

            ()    Single

            ()    Divorced

            ()    Living with a partner

 

37.  Are you experiencing financial difficulties because of your symptoms?

            ()    None at all

            ()    Only a little

            ()    Some

            ()    A lot

 

38.  Are you now or have you ever been a regular smoker?

            ()    No

            ()    Yes, I used to smoke regularly but quit ______ years ago.

            ()    Yes, I am currently smoking              packs per day / ______cigarettes per day

 

39.  How many drinks (beer, wine, and liquor) do you have per week?

            ()    Less than one drink per week

            ()    Greater than one drink per week.  Average number/week is  ______.

            ()    I do not drink alcoholic beverages.

 

40.  Have you ever been told you are alcoholic or chemically dependent or been treated for alcohol or chemical dependency?

            ()    NO

            ()    YES

 

41.  Source of primary health care coverage for this injury (please check one).

            ()    Private Insurance

            ()    Medicare

            ()    Medicaid

            ()    HMO or PPO

            ()    Self-Pay

            ()    Automobile Insurance

            ()    Workers Compensation

 

42.  Do you think the fault of your current symptoms are  (please check the one best answer)

            ()    Yours

            ()    Your employer’s

            ()    A co-worker’s

            ()    Another person’s

            ()    Nobody’s

 

43.  Have you hired a lawyer because of your symptoms?

            ()    No, I have not hired a lawyer.

            ()    Yes, I have and the case is in litigation.

            ()    Yes, I have and the case has been settled.