When you present for assessment, regarding a spinal complaint, to one of the members of the Adelaide Spinal Clinic you will be asked to complete a questionnaire detailing the nature of your complaint.

Patient History Form

Marital status:                                      Number of children?                             

Occupation:                                         Number of pregnancies?                     

1    Date of onset of pain?                          

2    What was the cause of your pain?

3    Have you had back/neck pain before the present episode?       

4    Have you ever had neck or back surgery?                  

      When and what type?

5    Pain is worse in:

6    Do you get numbness or tingling in your legs?                  

7    Do you get numbness or tingling in your arms?                  

8    Is your pain getting                  

9    Is your pain                  

10  What activities make the pain worse?

11  What reduces your pain?

12  What treatment have you had?

13  List past operations (other than spinal surgery):

14  Do you exercise on a regular basis?                  

      How often:                                                                                                      

15  Do you smoke?                 

16  Please list your current medicines and pain pills :

17  Please rate your general health:

18  General medical problems:

19  Do you have bladder or bowel problems?                  

      Have they developed since the onset of your pain?                  

20  Allergies:                     Nil                     Yes (list below)

21  Is there a family history of back/neck trouble?                  

22  Name other specialists you have seen for this condition

23  Are you involved in litigation or compensation due to your back/neck problem?

24  Please indicate by a mark on the line below how much pain you have had in your neck or back on average during the past week.

     
 0            1            2            3           4            5            6            7            8            9          10
No Pain                                                                                                                      Worst Pain

25  Do you have to rest during the day because of your pain?

26  How often have you seen a doctor or had treatment (eg physiotherapy) for your pain?

27  At present, are you working?     (housewives relate activity to previous abilities)

28  At present, can you undertake sports or active pursuits? (eg dancing)

29  At present, can you undertake household chores or odd jobs?

30  Mark the box that describes best how much your back/neck pain affects each of the following activities.

31  How often do you have to take pain killers for your pain?

32  Choose the activity level from the list below that best represents your functional capacity

33  

 34  Indicate in RED the areas on your body where you feel pain. Shade in BLUE the areas on your
 body where you feel numbness, tingling or pins & needles.

Send mail to spine@adelaide.on.net  with questions or comments about this web site.
Last modified: February 18, 2002