Bernard A. Rawlins, M.D.

Bernard A. Rawlins, M.D. NEW PATIENT INFORMATION FORM Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. If you already completed this form in the last 2 months, please fill out just the first 2 pages and only items on other pages that have changed since your initial visit. Thank you for your cooperation. Date: Patient Name: Address: Date of Birth: Home Phone: ( ) Work: ( ) How were you referred to Dr. Rawlins: ❑ Physician ❑ Patient/ Friend ❑ Insurance 0 Other: Referring Physician or Referral Source: - Address: City, State: Phone: ( ) Fax:( ) Do you want your medical records sent to this physician/ referral source? ❑ Yes ❑ No Primary Doctor: Address: City: Phone: ( ) Fax: ( ) Do you want your medical records sent to this physician? ❑ Yes E No Are there any other physicians to whom you would like your medical records sent? (Please include name and address) EFTA00307789 FEB.03.2059 15:15 ALEXISJIESS.EDU Digital 5117 14823 P001 ORTHO PAIN CHART Mark the areas on your body where you feel the described sensations using the appropriate symbol from the list below. Please include all affected areas. ==. 000 Burning xxx 1/11 Numbness = = == Pins & Needles = 000 Aching = sm Stabbing = IIII === op° xxx NI Please indicate your current pain level by placing a line below with "0"- no pain and "10" = worst pain imaginable. Example: Pain Lo_ II0 Pain on Average 0 10 Pain at its Worst 0 Pain at its Best (lying dom. roil) 0 10 L 10 EFTA00307790 HISTORY OF PRESENT COMPLAINT 1. Age: ❑ Male ❑ Female 2. Where is your problem located? ❑Neck ❑ Lower Back ❑ Arm I Leg ❑ Right ❑ Left 3. How long have you had this problem? 4. Briefly, please give the details of how this problem originally started: Since? month day year 5. Was this from a work-related injury? ONo ❑ Yes Have you missed any work days because of this problem? ❑ No ❑ Yes, how much? 6. Please describe your present pain/problem now (what you feel, where, when, etc.): 7. List all other physicians with whom you have consulted in the past year for this problem. 8. Have you had spinal surgery in the past: (Check one) ❑ Yes ❑ No How many times? What type of surgery(s) wasAvere performed? Discectomy ❑ Laminectomy ❑ Fusion ❑ Unknown ❑ Other What spinal level? What was the date of your most recent spine surgery? Did you improve from your spine surgery procedure(s)? ❑Yes ❑ No 9. Which of the following best describes the percentage of neck & arm or back & leg discomfort (if appropriate) A. B. C. D. E. F. G. Back 100% back pain and 0% leg pain 90% back pain and 10% leg pain 75% back pain and 25% leg pain 50% back pain and 50% leg pain 25% back pain and 90% leg pain 10% back pain and 90% leg pain 0% back pain and 100% leg pain Neck A. 100% neck pain and 0% arm pain B. 90% neck pain and 10% arm pain C. 75% neck pain and 25% arm pain D. 50% neck pain and 50% arm pain E. 25% neck pain and 75% arm pain F. 10% neck pain and 90% arm pain G. 0% neck pain and 100% arm pain 3 EFTA00307791 CURRENT PAIN PROFILE 10. Please choose letters A- F (in first column) to answer the questions in column two. A. Unable to tolerate How long can you sit? B. About 15 minutes only C. About 30 minutes only How long can you stand? D. About 45 minutes E. About 1 how How long can you walk? F. Indefinitely 11. Which of the following activities change the nature of your pain? Aggravates Relieves Pain Pain Neither Sitting ❑ ❑ ❑ Standing ❑ ❑ ❑ Walking ❑ ❑ ❑ Leaning fonvard (brushing teeth) ❑ ❑ ❑ Bending forward ❑ ❑ ❑ Lying on your side ❑ ❑ ❑ Lying on your back ❑ ❑ ❑ Lying on your stomach ❑ ❑ ❑ Rising from sitting ❑ ❑ ❑ Changing positions ❑ ❑ ❑ Coughing/ Sneezing ❑ ❑ ❑ Driving ❑ c ❑ Now go back and CIRCLE the box to indicate the most wizravatinz activity and the most relievine activity. 12. Does your pain wake you up at night? ONo ❑Yes ❑ Daily less than 3days/week Omore than 3 days/week 13. If your pain has changed, please indicate the most appropriate statement: (Circle one) A. My symptoms are more severe since the time of onset. B. My symptoms have remained the same since the time of onset. C. My symptoms are less severe since the time of onset. 14. Please indicate whether you have had any of the following studies and write yearAvhere the most recent was: YES NO YEAR/WHERE Regular X-ray of spine ❑ ❑ CT scan of spine ❑ ❑ MRI ❑ ❑ Myelogram ❑ ❑ Bone Scan ❑ ❑ 4 EFTA00307792 15. Of the following list of treatments, please indicate the effect of those which have been used in an attempt to help your present injury: (Check one of each) Type/ Duration (weeks/ months) Helpful No Help Not Used Anti-inflammatory ❑ ❑ ❑ Muscle Relaxants ❑ ❑ ❑ Narcotic Pain Medications ❑ ❑ ❑ Hot Packs ❑ ❑ ❑ Ice ❑ ❑ ❑ Ultrasound ❑ ❑ ❑ TENS Unit/ Muscle Stim ❑ ❑ ❑ Physical Therapy (Duration) ❑ ❑ ❑ Back/ Neck Exercises ❑ ❑ ❑ Chiropractor ❑ ❑ ❑ Epidural Block/ Injection ❑ ❑ ❑ Facet Block/ Injection ❑ ❑ ❑ Trigger Point Injection ❑ ❑ ❑ Acupuncture ❑ ❑ ❑ Other: ❑ ❑ ❑ Allergies Medication Reaction Current Medications Name Dose 5 EFTA00307793 MEDICAL HISTORY ❑ No medical problems ❑ High blood pressure ❑ Heart attack ❑ Heart failure ❑ Abnormal heart rhythm ❑ Lung disease ❑ Tuberculosis ❑ Asthma ❑ Bronchitis ❑ Emphysema ❑ Liver disease ❑ Hepatitis Diabetes 0 Thyroid disease 0 Stomach ulcers O Irritable bowel 0 Stroke 0 Seizures 0 Cancer — where? O Kidney Failure O Kidney Stones 0 Osteoporosis 0 Osteoarthritis O Rheumatoid arthritis Are you under a doctor's care for any mother medical condition? If yes, please explain ❑ Bleeding disorders 0 Anemia O Blood clots in legs/ lung O Endometriosis 0 Ovarian cysts 0 Anxiety O Depression O Schizophrenia 0 Anorexia / bulimia 0 Alcoholism ❑ Seen a psychiatrist ❑ HIV ❑ Yes ❑ No ❑ Spine- Neck • Spine- Lower back Brain Ileart Angioplasty / = Stent Lung Other: SURGICAL HISTORY Please choose all surgeries you have had _Appendix / Intestine • Hernia / Colon/ 0 Rectum : Hysterectomy / 0 C-section / E Female • Kidneys / 0 Bladder / 0 Urinary • Shoulders / 0 Arms / 0 Hands • Hips / 0 Knees / 0 Legs / 0 Feet Eyes Ears Nose Throat/ :Tonsils .1 Prostate ❑Gallbladder/ ❑Stomach SOCIAL HISTORY 16. Martial Status: ❑ Single ❑ Married ❑ Divorced ❑ Widowed 17. Number of Children: 18. I live: 0 Alone ❑ With: 19. Are you a cigarette smoker? ❑ Yes ❑ Never ❑ Quit — How long ago did you quit? If you answered "yes" or "quit", how much do or did you smoke per day? ❑ Less than 1/2 pack ❑ I pack ❑ More (How many?) 20. Do you drink any alcoholic beverages? (Check one) 0 None ❑ 1 to 2 drinks per day ❑ Socially 21. Current work status: ❑ Occasionally 0 Working full duty ❑ Working restricted duty (Since ) ❑ Retired ❑ Disabled (Since ) ❑ Student ❑ Homemaker Company: Occupation: Title: ❑ Unemployed 6 EFTA00307794 22. Have you ever had a problem with drug dependence? El Yes ❑ No 23. Are there any law suits pending or contemplated related to your problem? ❑ Yes ONo 24. Please write any additional information that you feel is important for us to know. REVIEW OF SYSTEMS Please check off any current or recent problems you have GENERAL ❑ Unexplained weight loss Appetite change Fevers or chills Night Sweats Marked fatigue Difficulty Sleeping EAR, NOSE, THROAT ❑ Difficulty swallowing ❑ Hoarseness ❑ Loss of hearing ❑ Ear pain ❑ Nosebleeds EYES O Glasses ❑ Change of vision CARDIOVASCULAR ❑ Heart or chest pain ❑ Abnormal heartbeat O Poor heart function LUNG ❑ Cough ❑ Shortness of breath DIGESTIVE O Nausea or vomiting O Stomach pain or ulcers O Heartburn O Frequent diarrhea O Frequent constipation O Uncontrolled loss of stool O Blood in stool O Hemorrhoids SKIN O Frequent rashes O Frequent itchiness O Easy bruising O Swollen ankles NEUROLOGICAL O Seizures O Blackouts/ fainting Tremor I leadaches/ migraines MUSCULOSKELETAL O Joint pains/ Swelling O Muscle Aches GENITOURINARY O Burning on urination O Difficulty starting urination O Incontinence O Pelvic pain O Urinate at night more than once O Unable to completely empty bladder PSYCHIATRIC O Depression O Anxiety O Paranoia O Obsessive / compulsive behavior 7 EFTA00307795