INITIAL PATIENT QUESTIONNAIRE-

(1)

Patient Name:

DOB:

MR #:

UWH# 301320-DT (Rev. 10/23/12) Scan to Questionnaire-Health INITIAL PATIENT QUESTIONNAIRE-

REHABILITATION Page 1 of 6

University of Wisconsin Hospital and Clinics

600 Highland Avenue Madison, WI 53792

INITIAL PATIENT

QUESTIONNAIRE-REHABILITATION

The clinic is located at 6630 University Ave.

Middleton, WI 53562

Date: ___________________________________

Patient Address: _____________________________________________________________________________________________

Home Phone: ___________________________________________ Work Phone: ________________________________________

Age: _____________________ Height: ___________cm/inches Weight: __________ kg/lbs  Male  Female

Referring Physician’s Name: __________________________________________ Physician Phone: ________________________

Physician Address: ___________________________________________________________________________________________

Type of Practice (Internist, Surgeon, etc.): _______________________________________________________________________

CHIEF COMPLAINT:

Do you have-

Neck pain  Yes  No Upper back pain  Yes  No Shoulder pain  Yes  No Low back pain  Yes  No Arm pain  Yes  No Hip/Leg pain  Yes  No

Any other complaints: _________________________________________________________________________________________

If more than one area, which is worse? __________________________________________________________________________

How long have you had this problem? ___________________________________________________________________________

Did your symptoms follow an injury ? ___________________ If yes, please indicate:  Work  Auto accident  Other Describe: ____________________________________________________________________________________________

Circle your least and greatest pain levels over the past two weeks:

(None) 0---1---2---3---4---5---6---7---8---9---10 (Severe)

Describe your pain (check all that apply):

 Constant  Deep  Dull  Sharp  Intermittent  Throbbing  Stiffness  Aching  Shooting  Cramping  Burning  Stabbing

Is your pain worse (check one)

(2)

Patient Name:

DOB:

MR #:

University of Wisconsin Hospital and Clinics

600 Highland Avenue Madison, WI 53792

INITIAL PATIENT

QUESTIONNAIRE-REHABILITATION

The clinic is located at 6630 University Ave.

Middleton, WI 53562

Indicate which of the following activities increase ( I ) or decrease (D) your pain

When I first get out of bed __________ Standing __________

Getting up __________ Walking __________

Sitting __________ Bending back __________

Lying on my back/side __________ Lying on stomach __________

Leaning forwards __________ Coughing/Sneezing __________

Lifting/bending forwards __________ Twisting __________

Straining __________ Reaching over __________

Look up/turn head sideways __________ Washing/combing hair __________

Climbing stairs/walking up ramp __________ Going down stairs/ramp __________

Long car rides __________ Other ___________ __________

Have you had neck/back symptoms before?  Yes  No

Have you had previous back or neck surgery?  Yes  No If yes, describe: ______________________________________

Have you had prior episodes of back symptoms for which you received Worker’s Compensation?  Yes  No Is the purpose of this exam to determine disability status for the government or an insurance agency?  Yes  No Are you currently receiving any type of financial compensation for your back problem?  Yes  No

Do you have an attorney for your back problem?  Yes  No

Mark in the areas of your body where you now feel your typical pain. Include all affected areas. Use the appropriate symbols indicated below: Front Back

PAIN = XXXXXXXXX NUMBNESS = OOOOOO

Pain Diagram

(3)

Patient Name:

DOB:

MR #:

University of Wisconsin Hospital and Clinics

600 Highland Avenue Madison, WI 53792

INITIAL PATIENT

QUESTIONNAIRE-REHABILITATION

The clinic is located at 6630 University Ave.

Middleton, WI 53562

Date Location MRI: ________________________________________________________________________________________________________ CT Scan: ____________________________________________________________________________________________________ Myelogram: __________________________________________________________________________________________________ Bone Scan: __________________________________________________________________________________________________ EMG: _______________________________________________________________________________________________________ Xrays: ______________________________________________________________________________________________________ PREVIOUS TREATMENT:

Put a check next to each type of treatment you have had for your back/neck in the past. Then check the column that best describes the effect of the treatment.

Treatment

()

if you have Did it make things

()

had this Better Worse No change

Hot packs/ice ________ ______ ______ ______ Ultrasound ________ ______ ______ ______ Massage ________ ______ ______ ______ TENS/Electrical Stimulation ________ ______ ______ ______ Yoga/Tai-Chi ________ ______ ______ ______ Exercises ________ ______ ______ ______ Traction ________ ______ ______ ______ Bed Rest ________ ______ ______ ______ Pool Therapy ________ ______ ______ ______ Biofeedback ________ ______ ______ ______ Injections ________ ______ ______ ______ Braces/Splints ________ ______ ______ ______ Medication ________ ______ ______ ______ Acupuncture ________ ______ ______ ______ Chiropractic Adjustments ________ ______ ______ ______

MEDICAL HISTORY: Have you ever had:

 AIDS or HIV testing  Phlebitis or blood clots  Kidney Stones  Asthma/Breathing problems

 Stroke  Arthritis  Cancer  Thyroid trouble

 Seizures  Radiation/Chemotherapy  Kidney Infections  Ulcer Heart Attack Migraine or other severe head pain  Tuberculosis  High Blood Pressure

(4)

Patient Name:

DOB:

MR #:

University of Wisconsin Hospital and Clinics

600 Highland Avenue Madison, WI 53792

INITIAL PATIENT

QUESTIONNAIRE-REHABILITATION

The clinic is located at 6630 University Ave.

Middleton, WI 53562

REVIEW OF SYSTEMS:

()

all that apply.

PAST SURGICAL HISTORY:

Year Operation Place Hospitalized

_____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________

If you had previous back surgery;

What were your symptoms before the surgery? (indicate R for right side, L for left side, B for both sides and circle all that applies)

Neck Pain ________ Shoulder pain/numbness/weakness ________ Arm pain/numbness/weakness ________

Wrist/hand pain/numbness ________ Back Pain ________ Hip/buttock/thigh pain/numbness/weakness ________

Leg pain/numbness/weakness ________ Ankle/foot pain/numbness/weakness ________

Urinary complaints ________ Bowel Complaints ________ Impotence ________ Walking/gait disturbances ________

Balance/falls/clumsiness ________

Constitutional Allergy/Immune Neurological Musculoskeletal

Fever ________ Drug allergy ________ Paralysis ________ Joint stiffness/swelling ________

Chills ________ Seasonal allergy ________ Tremors ________ Muscle pain/swelling ________

Night sweats ________ Food Allergy________ Spasticity ________ Fatigue ________

Weight loss ________ Iodine allergy ________ Seizures ________ Fractures ________

Loss of appetite ________ Transplant ________ Muscle atrophy ________

Hemo-lymphatic CV/Respiratory Gastrointestinal Endocrine

Anemia ________ Shortness of breath ________ Difficulty swallowing ________ Obesity ________

Excessive bleeding ________ Wheezing ________ Heartburn ________ Thyroid Disorder _______

Easy bruising ________ Cough ________ Nausea/vomiting ________ Diabetes ________

Lymphoma ________ Coughing up blood ________ Constipation ________ Menopause ________

Leukemia ________ Chest Pains ________ Diarrhea ________ Menstrual irregularities____

Cancer ________ Palpitations ________ Blood in stools ________ Pelvic pain ________

Lymph node swelling ________ Leg swelling ________ Stomach pain ________ Addison’s disease _______

HENT Skin/Integumentary Genitourinary Psychiatric

Loss of vision ________ Rash ________ Pain urinating ________ Poor sleep ________

Eye Redness ________ Ulcer ________ Incontinence ________ Depression ________

Headaches________ Eczema ________ Blood in urine ________ Anxiety ________

Dizziness ________ Hives ________ Dribbling ________ Stress at work/home _____

Glaucoma ________ Sexual Difficulties ________ Panic Spells ________

(5)

Patient Name:

DOB:

MR #:

University of Wisconsin Hospital and Clinics

600 Highland Avenue Madison, WI 53792

INITIAL PATIENT

QUESTIONNAIRE-REHABILITATION

The clinic is located at 6630 University Ave.

Middleton, WI 53562

Did your symptoms improve after surgery? _______________________ If yes, how long afterwards? _____________________

Did you get worse after surgery? _________________________________ If yes, explain: ________________________________

Were you released back to work after surgery? ____________ If so, when? ___________________________________________

ALLERGIES:

Name of medicine/substance Type of reaction Date

_____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________

MEDICINES: List all medicines that you have taken recently. Include vitamins and non-prescription medicine.

1. __________________________________________ 5. __________________________________________

2. __________________________________________ 6. __________________________________________

3. __________________________________________ 7. __________________________________________

4. __________________________________________ 8. __________________________________________

FAMILY HISTORY:

Spinal Problems  Yes  No If yes, describe: ________________________________________________________

Bleeding Disorders  Yes  No If yes, describe: ________________________________________________________

Heart Disease  Yes  No If yes, describe: ________________________________________________________

Cancer  Yes  No If yes, describe: ________________________________________________________

Diabetes  Yes  No If yes, describe: ________________________________________________________

SOCIAL HISTORY:

How many years of schooling ? (circle one)

Less than high school high school graduate technical school diploma 1-3 years of college College graduate post graduate or professional degree

Marital Status: Single _________ Married _________ Divorced _________ Remarried _________ Widowed ____________ Separated _________

How many years? _________ Number of children? _________ Ages: _______________________________________________

Who lives with you at home? __________________________________________________________________________________

Working status:  Working  Not Working  Student  Disabled  Retired

(6)

Patient Name:

DOB:

MR #:

University of Wisconsin Hospital and Clinics

600 Highland Avenue Madison, WI 53792

INITIAL PATIENT

QUESTIONNAIRE-REHABILITATION

The clinic is located at 6630 University Ave.

Middleton, WI 53562

How long have you worked at your present job? ____________ If not working, last date worked: _________________________

Spouse’s Occupation: _________________________________________________________________________________________

Have you ever smoked?  Yes  No Type/Amount: ____________ Years: _________ If quit, when? _______________

Amount of alcohol consumed in a typical week? ____________ Cups of caffeinated drinks per day? ______________________

Have you used: Marijuana  Cocaine  Heroin  Other __________________________________________________

Do you get any regular exercise? Describe: ______________________________________________________________________

Completed by: ________________________________________________________________ Date: ___________________

If not completed by patient, relationship to patient: ________________________________________________________

Reviewed by: _______________________________________________ Date: _______________ Time: _______________