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 +
+ + |
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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
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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 |