Michigan Spine And Brain Surgeons Form printable pdf download

Michigan Spine And Brain Surgeons Form

MICHIGAN SPINE AND BRAIN SURGEONS PLLC

Name _______________________________________________

Have you had any medical changes in the last year?

Yes – Please update form

No – Please sign and date:

Signature __________________________________ Date ___________________________

Before your visit today, have you been to the following:

Urgent care facility

Rehab facility

A physician’s office

Hospital for surgery

If yes, please indicate the date of your visit and the reason:

Type of Facility and Date:

Reason for Visit:

Chief Complaint___________________________ When did the problem start __________________________________

Explain what difficulties bring you to Drs. Teck Soo/Peter Bono/Roderick Claybrooks/Ryan Barrett/Boyd Richards:

Percentage of pain in your body (0-100%), for example, BACK 60%, RIGHT LEG 30%, LEFT LEG 10%:

BACK _____________ (%)

RIGHT LEG _____________ (%)

LEFT LEG _____________ (%)

NECK _____________ (%)

RIGHT ARM _____________ (%)

LEFT ARM _____________ (%)

Have you undergone CAT scan?

Yes

Have you undergone EMG/nerve conduction study?

Yes

Have you undergone MRI scan?

Yes

Have you undergone X-Ray?

Yes

Have you undergone physical therapy?

Yes

Have you undergone pain clinic treatment?

Yes

Are your symptoms improved?

Yes

No, if yes, by how many percent? __________________________

Are your symptoms getting worse?

Yes

No, if yes, by how many percent? __________________________

Version 02/23/2014

Michigan Spine And Brain Surgeons Form