Version 1.8 Name: DOB: CAD ColumbiaDoctors

Version 1.8 Name: DOB: CAD ColumbiaDoctors Adult New Patient Intake Form Patient Information Last Name: -P3-7 First Name: Gender: 1\A Home Phone: Preferred Phone: Home or obile (circle one) Emergency Contact: KArgyNiA SWALIAK. Emergency Contact Phone: Occupation: BA )..1 g, Primary Care Provider (PCP): I .40.1-re..D OCAL--(14 e AgE PCP Phone: Referring Provider: be H AR g•/ FISCH Referring Phone: Preferred Pharmacy: y TA I-IE ACTS Pharm Phone: 2 I - 111O Preferred Pharmacy Address: 23S 1st AVE. errWr-1 (.46"4 ? (.91-7) /\1`) Ce_rp RG-\) DOB: 1-/LL Zia 1953 Mobile Phone: Email: jev a_ca.41 9 One:1/4; 1 • aenn Relationship: Fai el.Jh Patient Marital Status: S I AG LE Employer: s-re- scumieg,..1 . - 2'4-44) Please list ALL active treating physicians (i.e. pulmonologist, oncologist, internist, cardiologist, etc...) Doctor's Name: T)P.-. SH or.r) Specialty: A 42bl OL.-0CIZ -r Doctor's Name: Die • 6 IZUCE: DZKOVI/fri- Specialty: II4Tegi.113 -r Doctors Name: Specialty: Doctor's Name: Specialty: Collection of the following information is encouraged by federal health agencies. This information is used to monitor and improve the quality of care provided to all patients. Ethnicity: Race: o Decline Response o Decline Response 0 Black or African American o Hispanic or Latino ..Pr American-Indian or Alaska Native a Native Hawaiian or Pacific Islander Not Hispanic or Latino o Asian c Other Preferred Language: o Decline Response Patient Financial Obligation Agreement I understand that all applicable copayments and deductibles are due at the time of service. I agree to be financially responsible and make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to ColumbiaDoctors for services rendered. I authorize representatives of Columbia Doctors to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. Notice of Privacy Practices: Acknowledgement of Receipt I acknowledge that I was provided with a copy of the Columbia Doctors Notice of Privacy Practices (NOPP). Received o N/A (only if you received the notice from ColumbiaDoctors previously) Information Disclosure and Consent ColumbiaDoctors will provide you with the health plans that your provider(s) accepts*. If you decide to be treated by a provider who does not accept your health plan, you will be asked to sign a consent form agreeing that you accept treatment from that provider. I read and agree to all of the above (Financial Agreement, Notice of Privacy, Insurance Information). Patient or Legal Guardian Name (Print): -TE,Firiezy 11.1 — p Patient or Legal Guardian Signature: Date: Feb • H-10_01 *Please refer to our website: columbiadoctors.org, for a list of insurances accepted by your provider. Page 1 of 14 Updated: 6/2212016 EFTA00313814 Name: DOB: Columbia Doctors Reason for today's visit: General Medical Questionnaire Have you EVER had any of the following? Asthma/Breathing Problems oY oN Heart Disease/Disorder oY oN Arthritis oY oN Lung Disorder oY oN Bleeding/Clotting Disorder oY oN Liver Disease ❑ Y ❑ N Blood Pressure Disorder oY oN Neurological Disorder/Chronic Headaches. oY oN Blood Transfusion ❑Y oN Psychiatric Disorder/Illness oY oN Bowel/Stomach Problems oY oN Pulmonary Embolism/DVT oY oN Cancer oY oN Stroke oY oN Cholesterol Disorder 0Y oN Seizure or Epilepsy ❑ Y oN Diabetes oY oN Thyroid Disorder oY oN Eye Disorder (i.e. Glaucoma, cataract) Women Only: Gynecological Issues oY oY oN ❑N Urinary/Kidney Disorder oY oN Please list any other medical illnesses or problems and provide details for any of the above conditions: Please list all eries and hos• italizations and the a oximate date. Procedure/ Hospitalization Date Please indicate any major conditions/illnesses that your immediate family members have had: Relative Condition and description Living? If deceased, at what age? Mother oY oN Father oY oN Sibling oY oN Other: oY oN Do you currently smoke? in Y oN If no, previously? oY a N Years smoked Packs/day Do you use other tobacco products? oY o N Consume alcohol? oY oN If yes, drinks/week: Women Only: Any past pregnancies? to Y o N How many? How many deliveries? Version 1.8 Page 2 of 14 Updated: 6/224016 EFTA00313815 Name: DOB: Cit? ColumbiaDoctors Do you have any allergies to medications or other substances (pets, food, etc.)? ❑Y ❑N If es, lease list aller. ies and reactions (includin rash, hives throat swellin., ana •h laxis): Allergy Reaction Please list ALL of our current medications, includin Medication Name Review of Systems Please indicate ALL that you have experienced within the past 6 - 12 months. Constitutional Reaction over the counter medications su lements and herbs: Medication Name ❑YON Fever OYON Chills oYoN Fatigue OYON Feeling Poorly OYON Sweats Head, Eyes, Ears, Nose, and Throat ❑YON OYON OYON DYON OYON Vision Problem Decreased Hearing Double Vision Light Sensitivity Itchy Eyes Cardiovascular OYON Red Eyes OYON Eye Pain ❑YON Runny Nose OVEN Neck Stiffness OYON Nosebleed OYON Weight Gain (_Lbs) OYON Sleep Disturbances OYON Weight Loss (_ Lbs) ❑ Other: OYON Unexp. weight Change OYON Congestion OY❑N Hoarseness OYON Snoring OYoN Ringing in Ears OYON Dry Mouth OYON Vertigo OYON Flu-Like Symptoms OYON Earache OYON Sore Throat OYON Other: OYON Chest Pain OYON Palpitations OYON Leg Swelling Respiratory DYON Shortness of Breath OYON Cough DYON Rapid Breathing Gastrointestinal OYON Cold Extremities OYON Cold Hands or Feet OYON Leg Pain w/ Walking OYON Wheezing OYON Shortness of Breath OYON Chest Congestion OYON Irregular Heart Rhythm ❑YON Other: ❑YON Coughing Up Blood ❑YON Coughing Up Sputum ❑ Other: O OYON Abdominal Pain OYON Blood in Stool OYON Vomiting ❑YON Nausea Version 2.8 OYON Diarrhea OYON Black/Tarry Stools OYON Decreased Appetite OYON Yellow Skin ❑YON Change in Bowels ❑YON Vomiting Blood OYON Bowel Incontinence OYON Rectal Pain Page 3 of 14 ❑YON Painful Swallowing O Other: Updated: 6/2212016 EFTA00313816 Name: DYON Constipation Neurological OYON Headache OYON Dizziness OYON Decreased Strength OWN Poor Coordination Musculoskeletal DOB 42— ColumbiaDoctors OYON Trouble Swallowing MTh Heartburn OYON Unsteady OYON Disorientation OYON Confusion OYON Burning Sensation OYON Numbness [WON Tingling OYON Seizures OYON Fainting (Syncope) oYoN Tremor OYON Memory Lapses/Loss O Other: OYON Joint Pain OYON Neck Pain OYON Back Pain Genitourinary OYON OWN OYON OYON OYON Limb Pain OYON Joint Swelling OYON Muscle Cramps OWN Muscle Pain OYON Muscle Weakness ONION Leg Swelling O Other: Frequent Urination Incontinence Urinary Urgency Painful Urination Integumentary MEIN Rash OYON Dry Skin Psychiatric OWN Depression OYON Pelvic Pain OYON Nocturia OYON Itching- Genital OYON Change in Libido OYON Skin Wound OYON Change in A Mole OYON Itching OYON Painful Intercourse OYON Discharge- Vaginal OWN Vaginal Bleeding oYoN Irreg. Monthly Cycles OYON Unusual Growth OYON Heavy Period Bleeding ❑ Other: OYON Skin Cancer o Other: Hematologic/Lymphatic OWN Easy Bruising Endocrine OYON Anxiety OYON Easy Bleeding oOther: OVON Swollen Lymph Nodes ❑ Other: DYON Excessive Thirst oYoN Cold Intolerance DYON Heat Intolerance DYON Changes- Hair OYON Changes- Skin o Other: OFFICE USE ONLY: Provider Signature: Date: Version LS Page 4 of 14 Updated: 6/22)2016 EFTA00313817 CI? ColumbiaDoctors I Orthopedics Additional Orthopedic Department Form Office Use Only MRN N: Age: Height: Weight: Pulse: BP: BMI: Name of person completing form: JE.--F-Fe essisit-i Re ationship (if n Referring • • Address: /441-PA Aft' t 1's name: "Ni2• 1-)A04-`9 1•1. 1,1`lnne-4-1 Phone num Fax number: Would you like o copy o) today's consult note sent to this doctor?Bies ci No Primary care provider's name: ba tave E mccgow I T2- Phone number West PAL-m Address: 1+11 k . FL-Aet el "ra2. elite rt.Faxecmo number: Would you like o copy of todoy's consult note sent to this doctor? 0 yes 0 No 3 aq'Ol Reason for today's visit: Which side hurts? 0 Left O Right 0 Both How long has your reason for today's visit been going on? How did it start? Hand dominance: 0 Left 0 Right Pain description: ElDull O Sharp ['Tingling p Other: When does pain occur? 0 At rest ['With activity O At night O Other: Rate pain: (Check box) No pain 1 2 3 4 5 6 7 8 9 10 Most 0 0 0 0 Cl 0 0 extreme What reduces the pain? 0 Medicine 0 Ice 0 Heot O Rest ❑ Elevation Your problem has: 0 Improved 0 Worsened Any other symptoms associated with the current problem? Does your home have: (Check all that apply) [11 story 0 2 stories 03+ stories OEntrance steps 0 Elevator Do you take public transportation? 0 Y ON Do you exercise regularly? OY ON Are you involved in organized sports? 0 N r Required Information: — i Did this injury happen while working? 0 Yes 0 No Does this injury relate to an auto accident? 0 Yes 0 No Is this injury related to a pending lawsuit? 0 Yes 0 No rig 11-1-,aols7Patient Signature Date Couistau Likivkasrry MinicAl. CENTER NewYork- Presbyterian Page 5 of 14 Updated 3/29/17 EFTA00313818 CI' ColumbiaDoctors I Orthopedic Surgery Spine Adult Spine Supplement PLEASE USE BLUE OR BLACK INK ONLY NAME: TO Fr- a a-). c-.irs-rei4 DATE OF BIRTH: I -20 -53 DATE: FaS 17 2 0 19 I. Chief complaint (check all that apply): Other O Spinal Deformity (Scoliosis, Kyphosis, Flatback Syndrome, etc.) O Neck pain Arm: O Pain O Numbness O Weakness O Back pain Leg: O Pain O Numbness O Weakness 2. If recommended, please rate how interested you are in having surgery to treat your problem: A. 0 I I Not at all 5 I I Maybe 10 I I Definitely ALL PATIENTS SHOULD ANSWER THE FOLLOWING***** I. Coughing or sneezing O Increases O Sometimes increases O Does not increase the pain. 2. There is: O No loss of bowel or bladder control O Loss of bowel or bladder control since 3. I have: O Not missed any work because of this problem O Missed (how much?) 4. Treatments have included: O No medicines, therapy, manipulations, injections, or braces Neck Back Neck Back ❑❑❑❑❑❑❑ work. O Physical therapy, exercise O O Anti-inflammatory medications O Massage & ultrasound O O Narcotic medication O Traction O O Epidural steroid injections times which O Manipulation relieved the pain for (how long)? O Tens Unit O O Trigger point injections times which O Shoulder injections relieved the pain for (how long)? O Braces O O Other 5. Generally speaking, are your symptoms getting better or worse? (Fill in noe circle) O Getting much better O Getting somewhat better O Staying about the same O Getting somewhat worse O Getting much worse 6. If you had to spend the rest of your life with the symptoms you have right now, how would you feel about it? (Fill in one circle) OVery dissatisfied °Somewhat dissatisfied ONeutral °Somewhat satisfied OVery satisfied MY PAIN / DISCOMFORT IS: 0 1 2 3 4 1 I I 1 (circle number) I No Pain 5 I 6 7 8 9 10 1 I I 1 I Slighi Mild Moderate Severe Excruciating Pain as bad as it could be Page 6 of 14 CONTINUED ON NEXT PAGE EFTA00313819 Cil? ColumbiaDoctors I Orthopedic Surgery Spine NAME: jecir-gEN aPSIEIti Please fill in drawings: (shade the areas) Adult Spine Supplement DATE OF BIRTH: Si? DATE: FCIS ilk 02-012 ACHING 0 No 3 Yes LIFT LEFT RIGHT STABBING PAIN 0 No 0 Yes My main goal(s) today is (are) to get (check all that apply): ❑ Second opinion ❑ Recommendation for Physical therapy O Medications ❑ Injection treatments O Surgery If you have seen other surgeons for this problem and were not happy, why? O Didn't answer my questions O Had no suggestions on what to do ❑ Personality issues O Office staff problems O Spent too little time with me O Other Page 7 of 14 CONTINUED ON NEXT PAGE EFTA00313820 CI? ColumbiaDoctors I Orthopedic Surgery Spine NAME: JER-r---gc-A DATE OF BIRTH: DATE: B. Adult Spine Supplement For patients with NECK OR ARM problems: DON'T DO IF BEING SEEN FOR A BACK PROBLEM I. What % of your pain is neck pain and what % is arm pain? (check appropriate box) O Neck 0%, Arm 100% O Neck 10%, Arm 90% O Neck 25%, Arm 75% O Neck 50%, Arm 50% O Neck 60%, Arm 40% O Neck 75%, Arm 25% ❑ Neck 100%, Arm 0% 2. There is: O No arm pain O Arm pain is as follows (check the following): a. O Right 0%, Left 100% O Right 10%, Left 90% O Right 25%, Left 75% O Right 40%, Left 60% O Right 50%, Left 50% O Right 60%, Left 40% 0 Right 75%, Left 25% O Right 90%, Left 10% O Right 100%, Left 0% b. The arm pain is present in the (check the following): Right: O Upper back 0 Shoulder O Upper arm Left: O Upper back O Shoulder O Upper arm 3. Raising the arm: O Improves the pain O Worsens the pain 4. Moving the neck: O Improves the pain O Worsens the pain 5. There is: O No weakness of the arms and hands O Weakness of the (check the following): O Forearm O Forearm ❑ Does not affect the pain O Does not affect the pain O Neck 40%, Arm 60% O Neck 90%, Arm 10% O Hand/finger O Hand/finger Right: O Shoulder O Upper arm O Forearm Left: O Shoulder O Upper arm O Forearm ❑ Hand/finger O Hand/finger 6. There is: O No numbness of the arms and hands O Numbness of the (check the following): Right: O Upper arm O Forearm O Thumb O Index finger O Long finger O Ring finger O Small finger Left: O Upper arm O Forearm O Thumb O Index finger O Long finger O Ring finger O Small finger 7. There ( O is O is no) difficulty picking up small objects like coins or buttoning buttons. 8. There ( O is a O is no) problem with balance or tripping frequently. 9. There are: ( O Frequent O Occasional O No) headaches in the back of the head. Patients with HEADACHES. I. If you have headaches, how would you describe their intensity and frequency? I have (check one): 0 slight Omoderate 0 severe headaches They come (check one): 0 infrequently O frequently O almost all the time 2. The headaches are located (check the following): a. O In the back of my neck b. O In the back of my head c. O The side of my head/temple area d. O In the front of my head (near my eyes) 3. How long have you suffered from headaches? O Several days O Several weeks O Several months O Greater than I year 4. When do the headaches occur most commonly? O Morning O Afternoon O While at work O Evening O No pattern 5. What is your average headache pain level throughout the day? (please circle) 0 1 2 3 4 5 6 7 8 9 10 6. How would you describe your pain? O Throbbing O Squeezing O Pressure O Dull O Stabbing O Shooting 7. What medications (either prescription or over-the-counter) do you take for your headaches? CONTINUED ON NEXT PAGE Page 8 of 14 EFTA00313821 gig ColumbiaDoctors I Orthopedic Surgery Spine Name: -37e.-FP- 6‘) Ggs-rfr..) DOB: -19- S3 DATE: Z +- it? THE NECK DISABILITY INDEX Adult Spine Supplement This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage everyday activities. It is important that you answer each of the following questions. We realize that you may feel that more than one statement may relate to you, but please circle the ONE BEST ANSWER to each question which closely describes your problem right now. Pain Intensity 0. I have no pain at the moment 1. The pain is mild at the moment. 2. The pain comes and goes and Is moderate. 3. The pain is moderate and does not vary much. 4. The pain is severe but comes and goes. S. The pain is severe and does not vary much. Personal Care 0. I can look after myself without causing extra pain. 1. I can look after myself normally but it causes extra pain. 2. It is painful to look after myself and I am slow and careful. 3. I need some help, but manage most of my personal care. 4. I need help every day in most aspects of self-care. S. I do not get dressed; I wash with difficulty and stay in bed. Lifting 0. I can lift heavy weights without extra pain. 1. I can lift heavy weights, but it causes extra pain. 2. Pain prevents me from lifting heavy weights off the floor but I can if they are conveniently positioned, for example on a table. 3. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. 4. I can lift very light weights. 5. I cannot lift or carry anything at all. Reading 0. I can read as much as I want to with no pain in my neck. 1. I can read as much as I want with slight pain in my neck. 2. I can read as much as I want with moderate pain in my neck. 3. I cannot read as much as I want because of moderate pain in my neck. 4. I cannot read as much as I want because of severe pain in my neck. 5. I cannot read at all. Headache 0. I have no headaches at all. 1. I have slight headaches which come infrequently. 2. I have moderate headaches which come in- frequently. 3. I have moderate headaches which come frequently. 4. I have severe headaches which come frequently. 5. I have headaches almost all the time. Concentration 0. I can concentrate fully when I want to with no difficulty. 1. I can concentrate fully when I want to with slight difficulty. 2. I have a fair degree of difficulty in concentrating when I want to. 3. I have a lot of difficulty in concentrating when I want to. 4. I have a great deal of difficulty in concentrating when I want to. S. I cannot concentrate at all. CONTINUED ON NEXT PAGE Page 9 of 14 EFTA00313822 gb ColumbiaDoctors I Orthopedic Surgery Spine Work 0. I can do as much work as I want to. 1. I can only do my usual work, but no more. 2. I can do most of my usual work, but no more. 3. I cannot do my usual work. 4. I can hardly do any work at all. 5. I cannot do any work at all. Driving 0. I can drive my car without neck pain. 1. I can drive my car as long as I want with slight pain in my neck. 2. I can drive my car as long as I want with moderate pain in my neck. 3. I cannot drive my car as long as I want because of moderate pain in my neck. 4. I can hardly drive my car at all because of severe pain in my neck. 5. I cannot drive my car at all. Office Use Only: Score Adult Spine Supplement Sleeping 0. I have no trouble sleeping 1. My sleep is slightly disturbed (less than 1 hour sleepless). 2. My sleep is mildly disturbed (1-2 hours sleepless). 3. My sleep is moderately disturbed (2-3 hours sleepless). 4. My sleep is greatly disturbed (3-5 hours sleepless). 5. My sleep is completely disturbed (5-7 hours sleepless). Recreation 0. I am able engage in all recreational activities with no pain in my neck at all. 1. I am able engage in all recreational activities with some pain in my neck. 2. I am able engage in most, but not all recreational activities because of pain in my neck. 3. I am able engage in a few of my usual recreational activities because of pain in my neck. 4. I can hardly do any recreational activities because of pain in my neck. 5. I cannot do any recreational activities at all Z'I'P-1Q Patient Signature and Date Physician Signature and Date Page 10 of 14 CONTINUED ON NEXT PAGE EFTA00313823 QID. ColumbiaDoctors I Orthopedic Surgery NAaille IC51/41 ePSTEW DATE OF BIRTH: kV) gg DATE: C. For patients with BACK OR LEG Problems: Adult Sphie Supplement 2--rk—kr DON'T DO IF BEING SEEN FOR A NECK PROBLAV I. What % of your pain is back pain and what % is leg or buttock pain? (check appropriate box): O Back 0%, Leg 100% O Back 10%, Leg 90% O Back 25%, Leg 75% O Back 40%, Leg 60% ❑ Back 50%, Leg 50% O Back 60%, Leg 40% O Back 75%, Leg 25% O Back 90%, Leg I 0% ❑ Back 100%, Leg 00/0 2. There is: O No leg pain O Leg pain as follows (check the following): a. O Right 0%, Left 100% O Right 10%, Left 90% O Right 25%, Left 75% O Right 40%, Left 60% ❑ Right 50%. Left 50% ❑ Right 60%, Left 40% O Right 75%. Left 25% O Right 90%. Left 10% ❑ Right 100%, Left 0% b. The pain is present in the (check the following): Right: O Buttock O Thigh-front O Thigh-back O Calf O Foot Left: O Buttock O Thigh-front O Thigh-back O Calf O Foot 3. There is: O No weakness of the legs O Weakness of the (check the following): Right: O Thigh O Calf O Ankle O Foot O Big toe Left: O Thigh O Calf O Ankle O Foot O Big toe 4. There is: O No numbness of the legs O Numbness of the (check the following): Right: O Thigh O Calf O Foot Left: O Thigh O Calf O Foot 5. The worst position for the pain is: O Sitting O Standing O Walking 6. How many minutes can you stand in one place without pain? O 0-10 O 15-30 O 30-60 O 60+ 7. How many minutes can you walk without pain? O 0-10 O 15-30 O 30-60 O 60+ 8. Lying down: O Eases the pain O Does not ease the pain O Sometimes eases the pain 9. Bending forward: O Increases the pain O Decreases the pain O Doesn't affect the pain In the past week, how often have you suffered: (Please circle the number that applies) None of A little of Some of A good bit Most of All of the time the time the time of the time the time the time 10. Low back and/or buttock pain 2 3 4 5 6 11. Leg pain 2 3 4 5 6 12. Numbness or tingling in leg and/or foot 2 3 4 5 6 13. Weakness in leg and/or foot (such as difficulty lifting foot) I 2 3 4 5 6 In the past week, how bothersome have these symptoms been? (Please circle the number that applies) Not at all Slightly Somewhat Moderately Very Extremely bothersome bothersome bothersome bothersome bothersome bothersome 14. Low back and/or buttock pain 2 3 4 5 6 15. Leg pain 1 2 3 4 5 6 16. Numbness or tingling in leg and/or foot 1 2 3 4 5 6 17. Weakness in leg and/or foot (such as difficulty lifting foot) 1 2 3 4 5 6 CONTINUED ON NEXT PAGE Page 11 of 14 EFTA00313824 di ColumbiaDoctors I Orthopedic Surgery Spine For patients with a SPINAL DEFORMITY/ BACK CURVATURE. 1. How was your spinal deformity discovered? 2. Do you know your present curve measurement(s)? 3. Rcason(s) for seeking treatment at this time: ❑ progressive deformity ❑ pain ❑ can't stand straight ❑ I don't like the appearance of my back/waistline ❑ Other: Page 12 of 14 Adult Spine Supplement CONTINUED ON NEXT PAGE EFTA00313825 Cifg ColumbiaDoctors I Orthopedic Surgery Spine Name: ,Teree`i c-PS-rEilJ DOB: I —20"53 DATE: THE BACK DISABILITY INDEX Adult Spine Supplement 2- iti--15? This questionnaire is designed to enable us to understand how much your back pain has affected your ability to manage everyday activities. It is important that you answer each of the following questions. We realize that you may feel that more than one statement may relate to you, but please circle the ONE BEST ANSWER to each question which closely describes your problem right now. Pain Intensity Walking 0. I can tolerate the pain I have without having to use pain killers. 0. Pain does not prevent me from walking any distance. 1. The pain is bad but I manage without taking pain 1. Pain prevents me walking more than 1 mile. killers. 2. Pain prevents me walking more than 1/2 mile. 2. Pain killers give complete relief from pain. 3. Pain prevents me walking more than 1/4 mile. 3. Pain killers give moderate relief from pain. 4. I can only walk using a stick or crutches. 4. Pain killers give very little relief from pain. 5. I am in bed most of the time and have to crawl to 5. Pain killers have no effect on the pain, I do not use them. the toilet. Personal Care (Washing, Dressing, etc.j Sitting 0. I can look after myself normally without it causing 0. I can sit in any chair as long as I like. extra pain. 1. I can only sit in my favorite chair as long as I like. 1. I can look after myself normally but it causes extra 2. Pain prevents me from sitting more than one hour. pain. 3. Pain prevents me from sitting more than thirty 2. It is painful to look after myself and I am slow and minutes. careful. 4. Pain prevents me from sitting more than ten 3. I need some help but manage most of my personal minutes. care. 5. Pain prevents me from sitting at all. 4. I need help every day in most aspects of self-care. 5. I do not get dressed, wash with difficulty and stay in bed Lifting Standing 0. I can lift heavy weights without extra pain. 0. I can stand as long as I want without extra pain. 1. I can lift heavy weights but it gives extra pain. 1. I can stand as long as I want but it gives extra pain. 2. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently 2. Pain prevents me from standing more than one hour. positioned. (e.g., on a table.) 3. Pain prevents me from standing more than thirty 3. Pain prevents me from lifting heavy weights, but I minutes. can manage light to medium weights if they are conveniently positioned. 4. Pain prevents me from standing more than ten minutes. 4. I can lift only very light weights. 5. Pain prevents me from standing at all. 5. I cannot lift or carry anything at all. CONTINUED ON NEXT PAGE Page 13 of 14 EFTA00313826 CI ColumbiaDoctors I Orthopedic Surgery Spine Sleeping 0. Pain does not prevent me from sleeping well. 1. I can sleep well only by using tablets. 2. Even when I take tablets I have less than six hours sleep. 3. Even when I take tablets I have less than four hours sleep. 4. Even when I take tablets I have less than two hours sleep. 5. Pain prevents me from sleeping at all. Employment/Homemaking 0. My normal homemaking/job activities do not cause pain. 1. My normal homemaking/job activities increase my pain, but I can still perform all that is required of me. 2. I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities. (e.g. lifting, vacuuming). 3. Pain prevents me from doing anything but light duties. 4. Pain prevents me from doing even light duties. 5. Pain prevents me from performing any job or homemaking chores Office Use Only: Score 2-4-1 Patient Signature and Date Adult Spine Supplement Social life 0. My social life is normal and gives me no extra pain. 1. My social life is normal but increases the degree of pain. 2. Pain has no significant effect on my social life apart from limiting my more energetic interests, (e.g., dancing, etc.). 3. Pain has restricted my social life and I do not go out as often. 4. Pain has restricted my social life to home. S. I have no social life because of pain. Traveling 0. I can travel anywhere without extra pain. 1. I can travel anywhere but it gives extra pain. 2. Pain is bad but I manage journeys over two hours. 3. Pain restricts me to journeys less than one hour. 4. Pain restricts me to short journeys under thirty minutes. 5. Pain prevents me from traveling except to the doctor or hospital. Physician Signature and Date Page 14 of 14 EFTA00313827