Swedish Neuroscience Specialists

Personal Health History

(To be completed by patient)

Patient Name:_________________________________________________ Date of Birth: _____/_____/_____

Sex______ Age______ Date:______/______/______

Referring Physician:____________________________________________________________________________

What part of your spine is your main concern today? (Check all that apply)
Low Back/Leg(s) _____ Neck/Arm(s) _____ Thoracic spine_____ Other_____

Onset
When did this set of CURRENT problems begin?_______________________________________________
When did they become serious enough to consider seeking medical care?___________________________
What is your chief complaint? ______________________________________________________________
What event(s) caused your current spine problem? (Check all that apply)

___ Gradual onset ___ Reaching ___ Lifting ___ Don’t know
___ Fall ___ Twisting ___ Pushing ___ Not applicable
___ Direct blow ___ Bending ___ Pulling ___ Other________________________

What were the circumstances surrounding this onset? (Check all that apply)

___ Vehicle/Boating accident ___ Recreational sport ___ Repetitive injury

___ On the job injury ___ Non-work related incident ___ No known cause
___ Other___________________________________________________________________________

Please explain these events that surrounded the onset of this spine problem:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Do you feel your employer or another person caused this spine problem? ___ yes ___no

Prior Spine Problems

Prior to this current set of spine problems, have you had prior issues regarding THIS CURRENT AREA of
your spine? _____ yes _____ no
Approximately when did these problems begin? ________________________________________________
What were the circumstances surrounding the onset of these problems?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

How many prior surgeries have you had in the area of the spine that is being addressed today? _______
Have your current spine problems been on going since they first started _____yes _____no

Page 1
Current Status
Mark the area on your body where you feel your typical pain. Include all affected areas. Use the appropriate symbols
indicated below

Pain Severity
1. If 10 is the worst pain imaginable, and 0 is no pain, please note your pain over the last TWO
WEEKS:
a) Please range your WORST pain. 0 1 2 3 4 5 6 7 8 9 10
b) Please rate your LEAST pain. 0 1 2 3 4 5 6 7 8 9 10
c) Please rate your overall or AVERAGE pain. 0 1 2 3 4 5 6 7 8 9 10

2. In the last week, how many days did you have your usual pain? 0 1 2 3 4 5 6 7

3. In the last week, during your waking hours, about what percentage of the day were you in pain
Less than 10% 10 – 59 % 50 – 75% 75 – 100%
It also bothers me at night

4. Do you have both back and leg pain? Yes No If yes, please answer the following 3
questions:

a) Which is worse, your back pain or your leg pain?  Back pain  Leg pain  About
equal
b) Do you often have just back pain without leg pain? Yes No
c) Do you often have just leg pain without back pain? Yes No

5. Do you have both neck and arm pain? Yes No If yes, please answer the following 3
questions:

a) Which is worse, your neck pain or your arm pain?  Neck pain  Arm pain  About equal
b) Do you often have just neck pain without arm pain? Yes No
c) Do you often have just arm pain without neck pain? Yes No

Page 2
Patient Name:_________________________________________________ Date of Birth: _____/_____/_____

Pain Severity, continued

6. Check the worst and best times for your pain:
Worst Best If you have NIGHT pain, does it:
 First awakening  First awakening  Prevent you from falling asleep?
 Morning  Morning  Awaken you at night?
 Afternoon  Afternoon  Hurt worse when lying down at night
 Evening  Evening than during the day?
 Nighttime  Nighttime

7. What does each of the following activities do to your pain?

No Change Relieves Pain Increases Pain

Sitting _______ _______ _______
Standing _______ _______ _______
Walking _______ _______ _______
Lying Down _______ _______ _______
Bending forward _______ _______ _______
Bending Backward _______ _______ _______
Lifting _______ _______ _______
Coughing / Sneezing _______ _______ _______
Looking up _______ _______ _______
Looking down _______ _______ _______

8. What do you do to relieve your pain?

1) ___________________________________________________________________________________

2) ___________________________________________________________________________________

3) ___________________________________________________________________________________

4) ___________________________________________________________________________________

Progression:
1. How is your current pain, compared to when this pain episode first started?
 Much improved  Somewhat improved  No change  A little worse  Much worse  N/A
2. How much change do you expect in your pain 6 months from now?
 Worse  No change  Some improvement  Marked improvement  Total relief

Bladder Function
If you have had any change in your bladder function, do you:
 Urinate more often
 Have loss of control or accidents
 Have a sense of urgency
 Have a loss of sensation around groin or buttocks
 Have problems with sexual function
 Have had no change

Page 3
 Function
1. Pain intensity (mark only one)
 I can tolerate the pain I have without having to use pain killers
 The pain is bad but I manage without taking pain killers
 Pain killers give complete relief from pain
 Pain killers give moderate relief from pain
 Pain killers give very little relief from pain
 Pain killers have no effect on the pain, I do not use them

2. Personal Care (washing, dressing, etc.) (mark only one)

 I can look after myself normally without it causing extra pain.
 I can look after myself normally but it causes extra pain
 It is painful to look after myself and I am slow and careful
 I need some help but manage most of my personal care
 I need some help everyday in most aspects of self care.
 I do not get dressed, wash with difficulty, and stay in bed

3. Lifting (mark only one)

 I can lift heavy weights without extra pain
 I can lift heavy weights but it gives extra pain
 Pain prevents me from lifting heavy weights off the floor, but I can manage if they are
conveniently positioned (e.g., on a table)
 Pain prevents me from lifting heavy weights but I can manage light to medium weights if they
are conveniently positioned
 I can lift only very light weights
 I cannot lift or carry anything at all

4. Walking (mark only one)

 Pain does not prevent me from walking any distance
 Pain prevents me walking more than 1 mile
 Pain prevents me walking more than ½ mile
 Pain prevents me walking more than ¼ mile
 I can only walk using a stick or crutches
 I am in bed most of the time and have to crawl to the toilet

5. Sitting (mark only one)

 I can sit in any chair as long as I like
 I can only sit in my favorite chair as long as I like
 Pain prevents me from sitting more than one hour
 Pain prevents me from sitting more than thirty minutes
 Pain prevents me from sitting more than ten minutes
 Pain prevents me from sitting at all

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Patient Name:_________________________________________________ Date of Birth: _____/_____/_____

6. Standing (mark only one)

 I can stand as long as I want without extra pain
 I can stand as long as I want but it causes extra pain
 Pain prevents me from standing more than one hour
 Pain prevents me from standing more than thirty minutes
 Pain prevents me from standing more than ten minutes
 Pain prevents me from standing at all

7. Sleeping (mark only one)

 Pain does not prevent me from sleeping well

 I can sleep well only by using tablets
 Even when I take tablets I have less than six hours of sleep
 Even when I take tablets I have less than four hours of sleep
 Even when I take tablets I have less than two hours of sleep
 Pain prevents me from sleeping at all

8. Employment/Homemaking (mark only one)

 My normal homemaking/job activities do not cause pain

 My normal homemaking/job activities increase my pain, but I can still perform all that is
required of me
 I can perform most of my homemaking/job duties, but pain prevents me from performing more
physically stressful activities (e.g., lifting, vacuuming)
 Pain prevents me from anything but light duties
 Pain prevents me from doing even light duties
 Pain prevents me from performing any job or homemaking chores

9. Social Life (mark only one)

 My social life is normal and gives me no extra pain

 My social life is normal but increases the degree of pain
 Pain has no significant effect on my social life apart from limiting my more energetic interests
(e.g., dancing, etc.)
 Pain has restricted my social life and I do not go out as often
 Pain has restricted my social life to home
 I have no social life because of pain

10. Traveling (mark only one)

 I can travel anywhere without extra pain
 I can travel anywhere but it gives me extra pain
 Pain is bad but I manage journeys over two hours
 Pain restricts me to journeys less than one hour
 Pain restricts me to short journeys under thirty minutes
 Pain prevents me from traveling except to the doctor or hospital

(MD Use) Score: ___________

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Social / Environmental History
Education:
High school diploma Yes No
GED Yes No
Did not complete high school or receive a GED Yes No
What is your highest level of education or training? ____________________________________________________

Are you Fluent in English? Yes No Other language __________________________________________

Marital Status:
What is your marital status?  Married/Partner  Divorced/Separated  Single  Widowed
Have you had a stress or change in a significant relationship within the past 12 months? Yes No
If yes, please explain: ____________________________________________________________________________
What are the ages of your children? _________________________________________________________________

Sleep:
Have you had any of these sleep problems at least half the days of the past month?
 Trouble falling asleep when you first go to bed Yes No
 Waking up during the night and not easily going back to sleep Yes No
 Waking up in the morning earlier than planned or desired Yes No
 Feeling unsatisfied or not rested by your night’s sleep Yes No
 Feeling excessively sleepy during the day (does not include regular naps) Yes No
How many hours per night do you sleep currently, on average? _____
Did your sleep problems exist prior to your current pain problem?  Yes  No  No sleep problems now

Mood:
These questions are about how you feel and how things have been with you during the past four weeks. For each
question, please give one answer that comes closest to the way you have been feeling.

Do you feel you might be depressed or overly anxious? Yes No

Circle the appropriate number to indicate the extent of the problem you are having with each of the following:
NONE SEVERE
Anxiety 0 1 2 3 4 5 6 7 8 9 10
Depression 0 1 2 3 4 5 6 7 8 9 10
Irritability 0 1 2 3 4 5 6 7 8 9 10

Have you ever considered yourself a victim of physical, emotional or sexual abuse? Yes No
Are you receiving care from a mental health professional? Yes No If yes, please explain____________________

Habits
1. Have you ever smoked? Yes No If yes, at what age did you start? ________
(Check all that apply) ___cigarettes ___cigars ___ pipe Age began: _____
2. During the time you smoke(d), indicate the average number smoked daily:
___less than 1 pack a day ___1 pack per day ____1 to 2 packs per day ___ more than 2 packs per day
3. If you’ve quit smoking, at what age? _____
4. How often do you have a drink containing alcohol?
___never ___monthly or less ___2-4 times a month ___ 2-3 times a week ___ 4 or more times a week
5. How many drinks containing alcohol do you have on a typical day when you are drinking?
___ 1 or 2 ___ 3 or 4 ___ 5 or 6 ___ 7 to 9 ___ 10 or more
6. Are you concerned about your drinking patterns? Yes No
7. Have any family members or friends expressed concerned about your drinking? Yes No

Page 6
Patient Name:_________________________________________________ Date of Birth: _____/_____/_____

Occupational History:
Employer: _______________________________ Date of hire: ________ Usual occupation: ___________________

Briefly describe your job: _________________________________________________________________________

1. How physically demanding is your job?

 Very heavy (frequently lifting over 50 pounds)  Light (frequently lifting under 10 pounds)
 Heavy (frequently lifting 25-50 pounds)  Sedentary (essentially no lifting)
 Moderate (frequently lifting 10- 25 pounds)
2. Work status at the TIME OF ONSET of this episode of back/neck pain:
 Regular: full time  Retired
 Regular: part time  On public assistance
 Working modified job (e.g., light duty)  Permanent disability (pension, SSDI)
 Not currently in workforce/homemaker/student  Other_________________________
 Unemployed, looking for work
3. Work status TODAY
 Regular: full time  Retired
 Regular: part time  On public assistance
 Working modified job (e.g., light duty)  Permanent disability (pension, SSDI)
 On active disability time loss
 Not currently in workforce(i.e. homemaker/student)  Other_________________________
 Unemployed, looking for work
4. How satisfied are you with your job?
 Very satisfied  Satisfied  Dissatisfied  Worst job I’ve ever had  N/A
5. If your back/neck got completely better during the next few weeks, do you think your employer would let
you return to the job you had before this episode of back/neck pain?
Yes  Probably  Doubt it  Definitely not N/A

6. Is your employer able and willing to offer you job accommodations (e.g., light duty, part-time work, flexible
schedule, special equipment) if needed to allow you to work? Yes No Don’t Know  N/A
7. How certain are you that you will be working in 6 months? (circle one)
0 1 2 3 4 5 6 7 8 9 10
Not at all Certain Definitely

8. When do you expect to return to work?

 Next 2 weeks  2-6 weeks 6-12 weeks  3-6 months  more than 6 months  never  N/A

9. Are you planning to apply for permanent disability such as Social Security Disability (SSDI) or other
disability? (e.g., worker’s compensation) Yes No
10. Has your employer treated you fairly?
Yes No N/A If no, please explain: __________________________________________________

11. Has anyone in your family been on disability coverage? Yes No
If yes, what is the relationship to you? __________________________________________________________
12. Is a lawyer helping you with a claim or lawsuit related to your current pain or other symptoms?
Yes No If yes, explain briefly ________________________________________________________

Page 7
Treatments:
Please list the physicians, chiropractors, and/or osteopaths you have seen within the LAST YEAR for your
back/neck pain, along with the approximate dates.
Doctor’s Name Type of Doctor Approximate Dates
_______________________________________ ___________________________ __________________
_______________________________________ ___________________________ __________________
_______________________________________ ___________________________ __________________
_______________________________________ ___________________________ __________________
Put an “X” next to each treatment you have had for your back/neck pain in the past or currently. For each treatment you
have had, circle Yes or No in each column.
____Treatment Effect of Treatment_________________________________
Currently using? Helped No change Increased symptoms
____ Home exercise program Yes No 1 2 3
____ Bed rest Yes No 1 2 3
____ Hot packs/ice Yes No 1 2 3
____ TENS unit for home use Yes No 1 2 3
____ Back brace Yes No 1 2 3
____ Physical therapy Yes No 1 2 3
____ Massage Yes No 1 2 3
____ Chiropractic treatment Yes No 1 2 3
____ Osteopathic manipulation Yes No 1 2 3
____ Acupuncture Yes No 1 2 3
____ Epidural injections Yes No 1 2 3
____ Facet injections Yes No 1 2 3
____ Local (trigger point) injections Yes No 1 2 3
____ Under care of pain specialists Yes No 1 2 3
____ Other ___________________ Yes No 1 2 3

Diagnostic Tests:
Which of the following diagnostic tests have been done on your back/neck? Please indicate date for “yes” answers.
Workup No Yes Approximate Date Work up No Yes Approximate Date
Regular x-rays___ ___ ______________ Bone Scan ___ ___ _______________
___ ___ ______________ ___ ___ ______________
MRI Scan ___ ___ ______________ Discogram ___ ___ ______________
___ ___ ______________ ___ ___ ______________
CT Scan ___ ___ ______________ EMG/SSEP ___ ___ ______________
___ ___ ______________ ___ ___ ______________
Myelogram/ CT ___ ___ ______________ Bone Density ___ ___ ______________
___ ___ ______________ ___ ___ ______________
Other ___ ___ ______________

If you have had surgery on your Back and/or Neck (including chymopapain), please fill in the following for
each operation:
Date Type of Surgery and Surgeon Pain After Surgery (M.D. USE ONLY)
Worse Same Better
_______ _________________________________________ ____ ____ ____ ___________________________
_______ _________________________________________ ____ ____ ____ ___________________________
_______ _________________________________________ ____ ____ ____ ___________________________
_______ _________________________________________ ____ ____ ____ ___________________________

Page 8
Patient Name:_________________________________________________ Date of Birth: _____/_____/_____

Medical History
Date: ________________ HT: ____________ WT: __________ Dominant Hand:  Right  Left  Ambidextrous

Reason for this visit:

________________________________________________________________________________
____
Medical Problems: If yes, please explain:
Heart Trouble  Yes  No
 Heart Attack  Yes  No
 Heart Failure
 Stents or bypass to heart  Yes  No
 Abnormal Rhythms  Yes  No
 Yes  No
Peripheral Vascular Disease  Yes  No
 Bypass or stents to legs  Yes  No
Cerebrovascular Disease  Yes  No
 Stroke-No residuals  Yes  No
 Permanent Paralysis
 Multiple Temporary Strokes  Yes  No
 Yes  No
Asthma  Yes  No
 Do you take medication on regular basis?  Yes  No
 Do you take medications for only flare ups?
 Yes  No
COPD/Chronic Obstructive Pulmonary Disease  Yes  No
 Do you take medication on regular basis?  Yes  No
 Do you require oxygen?
 Yes  No
Ulcers  Yes  No
 Acid Reflux  Yes  No
Diabetes  Yes  No
 Age at onset ___________
Any Organ Damage?  Yes  No
Please list:
Kidney Problems  Yes  No
 Recurrent infections?  Yes  No
 Failure including dialysis?
 Yes  No
Inflammatory Arthritis  Yes  No
 Lupus/Rheumatoid Arthritis  Yes  No
 Need medication?
 Other ______________________________  Yes  No
 Yes  No
Liver Disease  Yes  No
 Mild  Yes  No
 Mod or Severe (Cirrhosis)
 Yes  No
Cancer  Yes  No
 Skin  Yes  No
 Leukemia/Lymphoma
 Other Malignancy  Yes  No
 Metastatic  Yes  No
 Yes  No
HIV Positive Disease  Yes  No
High Blood Pressure  Yes  No
Anemia  Yes  No
Bleeding Disorders  Yes  No
 Taking Blood Thinners  Yes  No
Gout  Yes  No
Thyroid  Yes  No
Psychiatric Care  Yes  No
Page 9
 Depression  Yes  No
 Anxiety  Yes  No

Medical Problems, continued

Prostate Problems  Yes  No

Neurologic  Yes  No
 Fever Related Childhood Seizures  Yes  No
 Meningitis  Yes  No
 Encephalitis  Yes  No
 Head Injury  Yes  No
 Seizures  Yes  No
Other  Yes  No
 List:

PRIOR SURGERIES (please list) Approximate PRIOR SURGERIES (please list) Approximate
Date Date

Have you EVER had any problems with surgery or anesthesia?  Yes  No Explain: ____________________________

Review of systems: Do you CURRENTLY have any of the following If yes, please explain:
problems? Please check answer that applies.
Neurological problems(i.e. Headaches, stroke,  Yes  No
memory loss, seizures)
Eye (i.e. glaucoma, cataracts, wandering or lazy eye)  Yes  No
Chronic Fever, unexpected weight loss, fatigue, poor  Yes  No
appetite, night sweats
Ear/Nose/Throat problems(i.e. hearing loss, sinus  Yes  No
problems)
Heart problems(i.e. chest pain, irregular heart beat,  Yes  No
tightness, trouble breathing lying flat, trouble
breathing when exercising, swollen ankles)
Respiratory problems(i.e. shortness of breath,  Yes  No
wheezing, coughing blood, persistent cough)
Gastrointestinal problems(i.e. nausea, heartburn,  Yes  No
abdominal pain, diarrhea, change in bowel habits,
excessive constipation, black or bloody stools)
Urinary problems(i.e. pain, incontinence, blood in  Yes  No
urine, urinate more at night )
Endocrine problems(i.e. diabetes, thyroid disease,  Yes  No
menstrual problems)
Reproductive problems (i.e. pregnancy, prostate  Yes  No
problems, impotence, etc.)
Musculoskeletal (morning stiffness, muscle  Yes  No
tenderness, dry eyes or mouth, white fingers in cold,
skin rashes, joint pain or swelling)

WOMEN ONLY:
Does your pain increase with your menstrual  Yes  No
periods?
Are you pregnant or possibly pregnant?  Yes  No
Do you take Birth Control Pills or Hormones?  Yes  No
Do you take at least 1000 mg of calcium daily?  Yes  No

Page 10
Patient Name:_________________________________________________ Date of Birth: _____/_____/_____

When was your last physical exam? _______________________ By Whom? __________________________

 If you have not had a physical within the last year and you have symptoms from the list, you MUST contact your
primary doctor. Please contact your PCP for general medical issues.

FAMILY HISTORY:
Please indicate if history of diabetes, cancer, heart disease, seizures, neurological, or other “family”
disease.
Living? Age or ages at death Present health or cause of death
Father  Yes  No
Mother  Yes  No
Spouse  Yes  No
Brothers # Living
# Deceased
Sisters # Living
# Deceased
Children # Living
# Deceased

MRI Information:
A. Do you have any metal implants such as:
Aneurysm clip(s):  Yes  No If yes, what year:
Cardiac pacemaker:  Yes  No If yes, what year:
Neuro-stimulator:  Yes  No If yes, what year:
Cochlear Implant:  Yes  No If yes, what year:
SWAN/EPI catheter:  Yes  No If yes, what year:
Bullets/Bullet fragments:  Yes  No If yes, what year:

B. Do you have significant claustrophobia:  Yes  No Will you need sedation:  Yes  No
C. Do you have a previous history of working with metal? (i.e. welder, sheet metal worker, etc.)  Yes  No
D. Are you allergic to IV contrast dye, Iodine or shellfish?  Yes  No
E. If female, is there a chance that you could be pregnant?  Yes  No

Living Situation:  Live Alone  With Family  With Friends  Homeless  Other

Referring Provider: Address: Phone:

Name:

Primary Care Provider: Address: Phone:

Name:

Legal Next of Kin: Address: Phone:

Name:

Page 11
Medication Record
In order to prevent mistakes with your medications, please transfer the information from the labels on
your prescription bottles to this sheet. Accurate information is required for your safety.

Name of Medication Dosage/Strength: Schedule: Reason for taking this

(e.g.: Plavix) (e.g.: 250mg) (e.g.: 1 tablet 2x per day) medication:

ALLERGIES:
Medication Allergies (List all) Reaction

Other Allergies (List all) Reaction

Tobacco use:  Never  Previously, but quit  Current _______packs per day.
Date stopped:
Use of Alcohol:  Daily  Moderately  Rarely  Never

Recreational Drug Use:  Never  Yes Type/Frequency:

Page 12
Patient Name:_________________________________________________ Date of Birth: _____/_____/_____

PHYSICAL EXAMINATION (Clinician Use Only)

Check mark means exam done. Blanks for abnormalities found.

ABNL NL
1) CONSTITUTIONAL: (measure 3)
_____ ____ Ht.______ Wt._____ BP______ Pulse____ Resp. _____ Temp_______

_____ ____ Appearace:_______________________________________________________

2) SKIN (area examined) TRUNK Head & Neck UE’s LE’s

_____ _____ Inspection _______ _______ _____ _____
_____ _____ Palpation _______ _______ _____ _____

_____ _____ Abnormalities found ______________________________________________

______________________________________________________________________________

3) PSYCHIATRIC
_____ _____ Orientation _______________________________________________________
_____ _____ Memory-Short term ___________________Long term_____________________
_____ _____ Affect/Mood ______________________________________________________
_____ _____ Judgment/Insight ___________________________________________________

4) HEAD & Neck: (enmt)

______ _____ Inspection/Palpation ________________________________________________
______ _____ Thyroid Exam _____________________________________________________

5) EYES
______ _____ E O M ___________________________________________________________
______ _____ Pupils____________________________________________________________
______ _____ Visual Fields ______________________________________________________

6) CARDIOVASCULAR R L (0,1+,2+)
_____ _____ Carotid Artery (bruits) ____ ____
_____ _____ Abnormal Aorta (size, bruits
PULSES R L (0,1+2+)
Femoral _____ ____
Popliteal _____ ____
Dorsalis Pedis _____ ____
Post Tibial _____ ____
_____ _____ Extremities (edema, varicosities, cyanosis, temperature) ____________________
______________________________________________________________________________

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ABN NL
7) RESPIRATORY
____ ____ Gen Assessment inspection __________________________________
____ ____ Lung Auscultation _________________________________________
____ ____ Symmetry of expansion _____________________________________
____ ____ Palpation of chest __________________________________________

8) LYMPHATIC (palpate 2)
____ ____ Neck _____Axilla ______Groin ________

9) GENITOURINARY
Inspection _____________________________________________
_____ _____ Rectal ___________Prostate ____________Sphincter tone

10a) MUSCULOSKELETAL-SPINE
____ _____ a) Gait _________________________________________________
____ _____ b) Station ______________________________________________
____ _____ c) Spine Area (neck, thoracic, lumbar) (circle area examined)
____ _____ d) Inspection (symmetry, masses, alignment)
____ _____ e) Myofascial pain (area tender)___________________________________

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Patient Name:_________________________________________________ Date of Birth: _____/_____/_____

ABN NL 10b) MUSCULOSKELETAL – Pelvis, Trunk, Ribs

_____ _____ Inspection/palp______________________________________________
_____ _____ Sciatic Notch Tender L______ R______
_____ _____ Ilio Tibial Band Tender L______ R______
_____ _____ Trendelenberg L______ R______
_____ _____ Iliac Crest ht L>R______ L>R______

11) NEUROLOGIC
_____ _____ a) Cranial Nerves_____________________________________________
b) Sensation
_____ _____ UE’s____________________________________________________
_____ _____ LE’s_____________________________________________________
c) Muscle Strength___________________________________________
_____ _____ UE’s____________________________________________________
_____ _____ LE’s_____________________________________________________

d) Reflexes (0, 1+, 2+, 3+)

R L R L
Biceps _______ _______ Quads _____ _____
Triceps _______ _______ Achilles _____ _____
BR _______ _______

e) Pathologic Reflexes

_____ _____ Hoffman’s L______ R______

_____ _____ Babinski’s L______ R______
_____ _____ Clonus L______ R______
_____ _____ Abdominal L______ R______

f) Tension signs

_____ _____ SLR: sit L______ R______

_____ _____ SLR: supine L______ R______
_____ _____ Femoral stretch L______ R______

1995 Exam Problem Focused Expanded Problem Detailed Comprehensive

Focused
Body Areas/Organ 1 Body Area/Organ 2-7 Body Areas/Organ 2-7 Body Areas/Organ 8+ Organ Systems or a
Systems System Systems Systems (Document at complete exam of a
least one or more in Single Organ System
detail)

Body Areas
Head (including face)
Neck
Chest (including breast/axilla)
Abdomen
Genitalia/Groin/Buttocks

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Time 99241 99242 99243 99244 99245
Minutes 15 30 40 60 80

This section for clinician use only

Pain # _____________ Pain # _____________

Location: Location:
Paraspinous R L B Sacroiliac R L B Paraspinous R L B Sacroiliac R L B
Trapezius R L B Sciatic Notch R L B Trapezius R L B Sciatic Notch R L B
Arm R L B Leg R L B Arm R L B Leg R L B
Other___________________________________ Other_________________________________

Character : Aching Burning Stabbing Character : Aching Burning Stabbing

Heavy Tingling Numbness Stiffness Heavy Tingling Numbness Stiffness
Weak Tired Grabbing _______ Weak Tired Grabbing _______

Frequency/week: 1-3 Days 4-6 Days Daily Frequency/week: 1-3 Days 4-6 Days Daily

Frequency/day: Intermittent Constant Frequency/day: Intermittent Constant

Amount/day: Occasional Some Most Amount/day: Occasional Some Most

Length of Pain: Seconds Minutes Hours Length of Pain: Seconds Minutes Hours

Worst Time of Day: First Arise Morning MidDay Worst Time of Day: First Arise Morning MidDay
Afternoon Evening Night All Afternoon Evening Night All

Best Time of Day: First Arise Morning MidDay Best Time of Day: First Arise Morning MidDay
Afternoon Evening Night All Afternoon Evening Night All

Increasing Factors: Look Up Look Down Use Arms Increasing Factors: Look Up Look Down Use Arms
Sit Stand Walk Bend Forward Sit Stand Walk Bend Forward
Bend Backward Off Feet Turn R Turn L Bend Backward Off Feet Turn R Turn L
Movement_______________________________________ Movement_____________________________________

Relieving Factors: Sit Stand Walk Relieving Factors: Sit Stand Walk
Bend Forward Bend Backward Off Feet Bend Forward Bend Backward Off Feet
Movement Crouching Change Position Hold Still Movement Crouching Change Position Hold Still
Meds___________________________________________ Meds________________________________________

Severity of Pain: Severity of Pain:

____________Mild nuisance ____________Mild nuisance
____________Mild to moderate, can live with it ____________ Mild to moderate, can live with it
____________Moderate, hard to deal with ____________Moderate, hard to deal with
____________Severe, ruining quality of life ____________Severe, ruining quality of life

Progression: Progression:
_________Little better __________Much better _________Little better __________Much better
_________Little worse __________Much worse _________Little worse __________Much worse
__________No change __________No change
Miscellaneous/Neurologic: Miscellaneous/Neurologic:

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