Dr. Wasserburger
SPORTS & SPINE ASSOCIATES
7756 Northcross Drive, Suite 203
Austin, Texas 78757
Phone: (512) 358-0500
Fax: (512) 358-0520

Sports and Spine Associates Logo

 

SPORTS & SPINE ASSOCIATES MEDICAL HISTORY

Name: ____________________________________ Age : ________
Referred By : _______________________________ Dominant Hand : R L
   
HISTORY OF ONSET  
When did this current Episode of pain / your problem begin? _________________________
Did the pain / problem begin: [ ] gradually [ ] suddenly  
How did this episode of pain begin?  
  [ ] Bending [ ] Twisting [ ] Pushing / Pulling  
  [ ] Lifting [ ] Fall [ ] Motor vehicle Accident  
  [ ] _______________________________________________________________________
If your pain is due to an injury, briefly describe the events that led to the injury.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Where are you experiencing your pain ? (Check all that apply)
[ ] Back [ ] Hip [ ] Thigh [ ] Knee [ ] Lower Leg [ ] Ankle/Foot  
[ ] Neck [ ] Shoulder [ ] Upper Arm [ ] Elbow [ ] Forearm [ ] Wrist/Hand  
Have you had prior episodes of this pain / problem? [ ] Yes [ ] No  
If yes, how many episodes have you had?  
When did the first episode begin?      
Is this episode worse than previous episodes? [ ] Yes [ ] No  
Do the episodes occur more readily and last longer? [ ] Yes [ ] No  
Explain what caused the prior episodes.      
Use the diagram and symbols to indicate where your pain is.  
Ache: AAA Burning:XXX Numbness:OOO Pins/Needles: …… Stabbing://///


If your pain is due to an injury, briefly describe the events that led to the injury.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
If you have back pain with leg pain or neck pain with arm pain, please answer the following :
*Do you ever have your back or neck pain without your leg / arm pain? [ ] Yes [ ] No
*Which statement best describes the ratio between your back/neck pain and leg/arm pain.
[ ] 90% back or neck pain and 10% leg or arm pain    
[ ] 75% back or neck pain and 25% leg or arm pain    
[ ] 50% back or neck pain and 50% leg or arm pain    
[ ] 25% back or neck pain and 75% leg or arm pain    
[ ] 10% back or neck pain and 90% leg or arm pain    

Please check the activities that affect the pain or your problem.
Better

Worse

No Change
Better
Worse
No Change
Coughing / Sneezing
[ ]
[ ]
[ ]
Bending Forward
[ ]
[ ]
[ ]
Straining
[ ]
[ ]
[ ]
Bending Backward
[ ]
[ ]
[ ]
Standing
[ ]
[ ]
[ ]
Lying on Back
[ ]
[ ]
[ ]
Walking
[ ]
[ ]
[ ]
Lying on Stomach
[ ]
[ ]
[ ]
Sitting
[ ]
[ ]
[ ]
Overhead Reaching
[ ]
[ ]
[ ]
Lifting
[ ]
[ ]
[ ]
Squatting
[ ]
[ ]
[ ]
Pushing/ Pulling
[ ]
[ ]
[ ]
Kneeling
[ ]
[ ]
[ ]
Driving
[ ]
[ ]
[ ]
Typing / Writing
[ ]
[ ]
[ ]
During Activity
[ ]
[ ]
[ ]
After Activity
[ ]
[ ]
[ ]

Affect of the Pain
*How many days of the week/months of the year do you typically have your pain/problem?______
*How much of the time during an average day do you have your pain / problem?
[ ] >1 hour [ ] 1-4 hours [ ] 4-8 hours [ ] Almost 24 hours [ ] Whenever not resting
*Is the pain / problem [ ] Intermittent [ ] Constant      
*How long WITHOUT A BREAK have you had your current pain / problem?
[ ] < 2 weeks [ ] 2-6 weeks [ ] 6-12 weeks [ ] 3-6 months [ ] > 6 months
*Mark an “X” for the WORST and an “O” for the best time of the day for your pain / problem.
[ ] Getting out of Bed [ ] Morning [ ] Mid-day [ ] Evening [ ] Nighttime
*Do you regularly curtail or miss social activities because of your pain / problem? [ ] No [ ] Yes
*Have you ever had ER / Hospital admissions because of your pain / problem? [ ] No [ ] Yes
* Please circle the number that best represents your average pain.
What is the LEAST?
0
1
2
3
4
5
6
7
8
9
10
What is the MOST?
0
1
2
3
4
5
6
7
8
9
10
What is it TODAY?
0
1
2
3
4
5
6
7
8
9
10

TREATMENT HISTORY
List the physicians and chiropractors that you have seen for your pain / problem
Doctor’s Name
Specialty
Location
Approx. Date.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Which of the following tests or treatments have been done for your pain / problem.
No Yes Date
What Area of Body /
Results
X-Rays
[ ]
[ ]
_______________________________________________
Bone Scan
[ ]
[ ]
_______________________________________________
MRI
[ ]
[ ]
_______________________________________________
CAT Scan
[ ]
[ ]
_______________________________________________
Myelogram
[ ]
[ ]
_______________________________________________
EMG / NCS
[ ]
[ ]
_______________________________________________
Discogram
[ ]
[ ]
_______________________________________________
Epidural Steroid Injection
[ ]
[ ]
_______________________________________________
Nerve Root Block
[ ]
[ ]
_______________________________________________
Facet Joint Injection
[ ]
[ ]
_______________________________________________
Sacroiliac Joint Injection
[ ]
[ ]
_______________________________________________
Other
[ ]
[ ]
_______________________________________________
       

If you had surgery for this or a similar problem, complete the following for each operation.
Surgery Type
Date
Worse
Same
Better
Length of Time / Type of Improvement
_____________________________
[ ]
[ ]
[ ]
________________________________
_____________________________
[ ]
[ ]
[ ]
________________________________
_____________________________
[ ]
[ ]
[ ]
________________________________

If you had surgery in the past, did you :
  [ ] Return to Work / Full Function [ ] Not Return to Work, But Full Function
  [ ] Return to Work, But Not Full Function [ ] Not Return to Work, Not Full Function

THERAPY        
If you have had therapy / chiro in the past, please indicate where, when and how long you attended.
_____________________________________________________________________________
Please place a check next to the type of treatment you received and how it affected your pain/problem.
Yes
Helped
No Effect
Made Worse
Hot Packs / Ultrasound
[ ]
[ ]
[ ]
[ ]
Ice / Cold Treatments
[ ]
[ ]
[ ]
[ ]
Massage / MFR / CSR
[ ]
[ ]
[ ]
[ ]
Traction
[ ]
[ ]
[ ]
[ ]
TENS
[ ]
[ ]
[ ]
[ ]
Muscle Stimulator
[ ]
[ ]
[ ]
[ ]
Chiropractic / Adjustments
[ ]
[ ]
[ ]
[ ]
Acupuncture
[ ]
[ ]
[ ]
[ ]
Bracing / Splinting
[ ]
[ ]
[ ]
[ ]
Strengthening Exercises
[ ]
[ ]
[ ]
[ ]
Flexibility Exercises /Yoga
[ ]
[ ]
[ ]
[ ]
McKenzie Exercises
[ ]
[ ]
[ ]
[ ]

Which helped the MOST? _________________________________________________
Which helped the LEAST? _________________________________________________
Are you currently receiving any of the aforementioned treatments now? [ ]Yes [ ]No
If Yes, please list which treatments you received when.____________________________________
_____________________________________________________________________________
_____________________________________________________________________________

OCCUPATIONAL HISTORY
Occupation : __________________________________________________________________
*Briefly describe your job duties : ___________________________________________________
_____________________________________________________________________________
What was you work status at the time of your injury?
[ ] Regular Duty, Full Time [ ] Permanent Light Duty [ ] On Disability Income
[ ] Regular Duty, Part Time [ ] Temporary Light Duty [ ] Retired, due to health
[ ] Homemaker or Student [ ] Unemployed [ ] Retired, NOT due to health
How long have you worked at your current job? ________________________________________
How physically demanding is/was you job? [ ] Sedentary [ ] Light [ ] Medium [ ] Heavy
How stressful is/was you job? [ ] Not at all [ ] Somewhat [ ] Very Much
Are / were you satisfied with your job? [ ] Very Much [ ] Somewhat [ ] Not much
How much do/did you like your co-workers? [ ] Very Much [ ] Somewhat [ ] Not much
How much do/did you like your supervisor? [ ] Very Much [ ] Somewhat [ ] Not much
If you are NOT currently working and your pain / problem got better in the next few weeks, do you
think your employer would return you to your regular job?
[ ] Yes [ ] No
     
LIFESTYLE HISTORY
Highest Education Level _____________________________ Race ______________________
Marital Status [ ] Single [ ] Married [ ] Separated [ ] Divorced [ ] Widowed
  [ ] # of Children & ages ______________ [ ] Children / Grands / Foster Living at Home? _______
Do you consider yourself to have a good social support system( family/friends)? [ ] No [ ] Yes
Are you experiencing financial difficulties because of your pain? [ ] No [ ] Yes
Have you had a prior Worker’s Compensation Claim? [ ] No [ ] Yes
Have you hired a lawyer because of your pain / problem? [ ] No [ ] Yes
Has anyone in your immediate family received money from:
[ ] Personal Injury Claim? [ ] Workers Comp Claim [ ] Disability Income
How many caffienated beverages do you drink per day / week? _______________ per day / week
Do you smoke? [ ] No [ ] Yes
If Yes, how many cigarettes do you smoke per day / week? _______________ per day / week
If you quit, how long did you smoke and when did you quit?
___________________________
How many alcoholic beverages do you drink per day / week? ______________ per day / week
Do you exercise regularly? [ ] No [ ] Yes If Yes, describe what type and how often
____________________________________________________________________________

PAST MEDICAL HISTORY
Medical Illnesses / Problems
Please check if you have had or are currently having problems with any of these illnesses / problems.
[ ] Diabetes [ ] Hypothyroid [ ] Depression
[ ] High Blood Pressure [ ] Osteoporosis [ ] Anxiety Disorder
[ ] Heart Disease [ ] Osteoarthritis [ ] Head Injury
[ ] Stroke [ ] Rheumatoid / Lupus / Gout or other connective tissue disorder
[ ] Other ___________________________________________________________________
Surgical History
Please check if you have had any of the following surgeries
[ ] Cardiac Bypass or Stint [ ] Gallbladder surgery [ ] C - section
[ ] Tonsillectomy [ ] Appendectomy [ ] Hysterectomy (if so, theage when it
[ ] Joint Surgery___________________________ occurred ____)
[ ] Spine Surgery__________________________
Injury History
Please include work or non-work injuries (fractures, major sprains or major injuries with no specific Dx
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Developmental History
Please note any developmental delays or the need for corrective bracing as a child / teenager.
  __________________________________________________________________________
  __________________________________________________________________________
Family History
Please check if any one in your immediate family has problems with any of these illnesses / problems.
[ ] Diabetes [ ] Hypothyroid [ ] Depression
[ ] High Blood Pressure [ ] Osteoporosis [ ] Anxiety Disorder
[ ] Heart Disease [ ] Osteoarthritis [ ] Head Injury
[ ] Stroke [ ] Rheumatoid / Lupus / Gout or other connective tissue disorder
[ ] Other ___________________________________________________________________
Primary Care Physician: ______________________ Date of last complete physical ___________
Medication Allergies: ____________________________________________________________
Medications:
Type
Dosage
How long have you been on it?
__________________________________________________________________________
__________________________________________________________________________
  __________________________________________________________________________
  __________________________________________________________________________
__________________________________________________________________________
Review of Systems: During the past year, have you had any of the following?
[ ] Unexplained Fevers [ ] Chest Pain or Tightness
[ ] Night Sweats [ ] Trouble Breathing [ ] Change in Bowel Habits
[ ] Unexplained Weight Loss [ ] Persistent Cough [ ] Black or Bloody Stools
[ ] Excessive Fatigue [ ] Swollen Ankles/Legs [ ] Change in Bladder Habits
[ ] Stiffness in Joints [ ] Hoarseness [ ] Painful Urination
[ ] Joint Swelling / Warmth [ ] Difficulty Swallowing [ ] Urinary Incontinence
[ ] Unusual Rashes [ ] Depression [ ] Menstrual Problems
[ ] Easy Bruising [ ] Anxiety [ ] Unusual Stress in Home Life
[ ] Nodes(groin/armpit/neck) [ ] Difficulty Sleeping [ ] Unusual Stress in Work Life

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