FOLLOW-UP QUESTIONNAIRE

Name: _______________ _______________ _______ Age:______

Last First Middle Initial

Date: _______/_______200____ Height: ____ft___in Weight: _______lbs

Last Procedure Date: ____/_____/____ Primary Treating M.D.: __________________

(circle one)

1. Since my last visit, my Back / Leg and Neck/ Arm symptoms are:

() Unchanged

() Improved, describe:

() Worsened, describe

2. Which of the following therapies have you tried since your last visit?

(Please check all that apply)

[] Pain pills (e.g., Tylenol with Codeine, Darvocet, etc)[] Antidepressants (e.g., Elavil, Prozac, etc.)

[] Chiropractic/Osteopathic Manipulations [] Physical Therapy, Describe:

[] Acupuncture [] Injections, Describe:

[] Muscle Relaxants (e.g., Flexeril, etc.) [] Other, Describe:

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

3. Have you had surgery since your last visit?

[] No

[] Yes, complete the following:

Date	Surgery Type (Please provide details.)	Change in condition after Surgery. (circle one)
		Same Better Worse for _________ months.

4. Have you had any of the following tests since your last visit?

Approx. Date Results (If Known)

[] MRI Scan

[] CT Scan

[] Myelogram

[] Discogram

[] EMG Test

[] Other

5. Who is the primary physician that is treating you for you spine condition?

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

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

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

Pain Pain

8. 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

9. 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 (please answer the following)

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

Questions # 10 - 13 apply only if you have had an injection procedure. If you have seen us for a consultation only, and have not had a procedure, please go to question # 14.

10. Did you have a flare-up after your procedure?

[] Yes

How long did it last? ____________ How severe was it? 0 – 10 scale ____________

[] No

11. Please check the statement that you feel best applies to your attitude toward the procedure you had.

[] The treatment met my expectations

[] I did not improve as much as I had hoped, but I would undergo the same treatment for the same outcome.

[] The treatment helped, but I would not undergo the same procedure for the same outcome.

[] I am the same or worse than before the treatment.

12. How would you rate the pain for which you had the procedure? (please check one)

[] Much Better

[] Better

[] Same

[] Worse

[] Much Worse

13. Which of the following best describes your current general overall activity level in comparison to before the procedure? (please check one)

[] Much Better

[] Better

[] Same

[] Worse

[] Much Worse

14. 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:

	FILL IN TIME	CHECK ONE	BOX ON	EACH LINE
Activity	Tolerance-Time in minutes	I Feel Better With…	I Feel Worse With	No Change (No effect)
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.

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

16. Have you increased or decreased your pain medication since your last visit? Yes No

(CIRCLE ONE) (CIRCLE ONE)

17. 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 + + +

CHECK THE MOST APPLICABLE (circle one)

Does My Back or Neck pain is ______ %

() back and legs hurt about the same not Better Worse Same (circle one)

() low back hurts much more than legs need

() low back hurts somewhat more than legs to (circle one)

OR equal My Leg or Arm pain is ______ %

() neck hurts much more than arms 100 % Better Worse Same (circle one)

() neck and arms hurt about the same

() neck hurts somewhat more than arms *** SPECIFY BETTER/WORSE/SAME

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

None	Occasional Non Narcotic	Daily Non Narcotic	Occasional Narcotic	Daily Narcotic
1	2	3	4	5

19. 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

20. 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

21. 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

22. 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

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

	Not at all bothersome	Slightly bothersome	Moderately bothersome	Very bothersome	Extremely bothersome
Low back/Neck pain	1	2	3	4	5
Leg /Arm pain	1	2	3	4	5

Staff use only:______