The Spine Center | Vietnam

Phone Number

Email  *

Date

Age  *

What do you expect to gain from today's visit?

Arms (2)

Middle Back (3)

Low Back (4)

Legs (5)

Arms

Middle Back

Low Back

Legs

Did you have an injury? Yes  No 

Exact Date of Injury

Details of Injury

Do you have a lawsuit or worker's compensation case pending? Yes  No 

How long have you had the pain?

What have you found that makes the pain worse or better?

Is your pain worse with coughing or sneezing Yes  No 

Is your pain worse at night? Yes  No 

Does it wake you at night? Yes  No 

Have you had any fever, chills or night sweats? Yes  No 

Have you had any recent unplanned or sudden weight loss? Yes  No 

Has there been any disturbance of bowel or bladder? Yes  No 

Is your leg pain worse with walking? Yes  No 

How far can you walk?

Is your leg pain relieved by resting? Yes  No 

Does your leg pain get better if you lean forward? Yes  NO 

Sitting makes your pain? Better  Worse  Unchanged 

Standing makes your pain: Better  Worse  Unchanged 

Lying down makes your pain: Better  Worse  Unchanged 

Physical activity makes your pain: Better  Worse  Unchanged 

Treatment dates & duration:

Chiropractic? Yes  No  N/A 

Treatment dates & duration:

Spinal Steroid Injections? Yes  No  N/A 

Did it make you feel better or worse

Treatment dates, and what type of injection?

Pain medications? Yes  No  N/A 

Did they help?

What medications?

CT SCAN

Myelogram

Bone scan

Blood tests

List the dates for conditions above or types for blood tests

Have you had surgery on your spine? Yes  No 

If so what type(s), what date(s) and name of surgeon?

Stroke

Malignant hyperthermia

Leg Blood Clot

Blood clotting disorder

Depression

Vascular Disease

Epilepsy

Osteoporosis

TB

Swallowing difficulty

HIV or AIDS

Multiple Sclerosis

Difficult anesthesia

Serious Infection

Immune disorder

Psychosis

Heart rhythm disturbance

Diabetes

Pulmonary Disease

Colon Problems

Hepatitis

Asthma

Heart Failure

Poor Circulation

Latex allergy

Bacteraemia

Anemia

Anxiety

Cancer

Lung Blood Clot

Liver Disease

Nickel allergy

Please list any other conditions not mentioned above

Cancer

Blood disorder

Stroke

Diabetes

Hypertension

Scoliosis

Anesthetic problems

Epilepsy

Please list any other conditions not mentioned above

Single

Divorced

Widowed

Working full time

Working part time

Retired

Unemployed

Student

Occupation

Does work involve lifting? Yes  No  Some  On Disability  Unable to work b/c of spine problem 

Do you have children? Yes  No 

If yes, what ages?

Smoker? Yes  No 

How many a day?

Smoked for how many years total?

Drinker? Non drinker  Drink rarely  Drink socially  Drink daily  Drink heavily 

Drugs/Narcotics Drugs or narcotics addiction  Use of non-prescription narcotics 

Psychiatric illness of any kind? Yes  No 

If yes, please give details

Are you taking any non-prescription medication at all? eg.Vitamins, herbs, health supplement. If so, please list them as these may sometimes affect you during any surgery

If yes, please list allergies to any medications, metals or latex

You would describe your ability to enjoy life as: Excellent  Good  Fair  Poor 

How did you hear about our clinic?

Additional Comments