New Patient Form – Cervical SpineCervical Spine – New Patient FormStep 1 of 714%PATIENT DETAILSTitle*SurnameName* First Name Preferred Name Address* Address Suburb Postcode Date of Birth* DD dash MM dash YYYY Email* PhoneReceive SMS PLEASE TICK IF YOU DO NOT WANT TO RECEIVE SMS MESSAGES FOR APPOINTMENT REMINDERSMEDICARE NO.PATIENT REFERENCE NO.EXPIRY DATE MM slash DD slash YYYY NEXT OF KINNAMERELATIONSHIPPHONEPHONE-IIPRIVATE HEALTH INSURANCEDO YOU HAVE PRIVATE HEALTH INSURANCE? Yes NoFUND NAMEMEMBER NO.VETERAN AFFAIRS NO.COLOUR OF CARDPENSION / HEALTH CARE NO.EXPIRY DATE MM slash DD slash YYYY LOCAL DOCTORNameAddress Address SUBURB POSTCODE TRANSPORT ACCIDENT TRANSPORT ACCIDENTCLAIM NO.DATE OF ACCIDENT MM slash DD slash YYYY WORKCOVER WORKCOVERCLAIM NO.PART OF BODY INJUREDEMPLOYERADDRESSCLAIMS OFFICER (NAME, TEL & FAX)INSURANCE COMPANYDATE OF INJURY MM slash DD slash YYYY SIGNIFICANT MEDICAL HISTORY DIABETIC ASTHMA / AIRWAYS DISEASE HEART DISEASE SLEEP APNOEA DO YOU TAKE ASPIRIN OR BLOOD THINNESS (PLEASE SPECIFY) PACEMAKER (PLEASE SPECIFY TYPE AND WHEN INSERTED) OTHER SIGNIFICANT MEDICAL HISTORY (PLEASE SPECIFY)DO YOU TAKE ASPIRIN OR BLOOD THINNESS (PLEASE SPECIFY)PACEMAKER (PLEASE SPECIFY TYPE AND WHEN INSERTED)OTHER SIGNIFICANT MEDICAL HISTORY (PLEASE SPECIFY)More DescriptionALLERGIES - PLEASE SPECIFYPAYMENT TERMSCONSULTATIONS: Payment is expected at the time of consultation.NON-ATTENDANCE: If 48 hours is not given for cancellation of an appointment a $50 fee applies.In the event an overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs.Overdue accounts will be subject to interest at the rate of 25% per annum, calculated for the period the account is due.I have been advised of costs for my consultation including telehealth fees.I have read the above Payment Terms and agree to abide by them.SIGNATUREDATE MM slash DD slash YYYY PLEASE PRINT YOUR NAMERELATIONSHIP TO PATIENT (EG SELF, PARENT, GUARDIAN)Consent* I consent to personal medical information such as test results being released to the following family members:I consent to the handling of my information by Victorian Orthopaedic Spine Service for the purposes set out above, subject to any limitations on access or disclosure that I notify in writing to Victorian Orthopaedic Spine Service. Click here to read morePATIENT NAMEDATE OF BIRTH MM slash DD slash YYYY SIGNEDDATE DD dash MM dash YYYY Patient History FormDate MM slash DD slash YYYY NAMEDATE OF BIRTH MM slash DD slash YYYY HEIGHTWEIGHTOCCUPATIONMARITAL STATUSDATE AND TIME OF THE ONSET OF YOUR PAIN? (IF KNOWN)WHAT WAS THE CAUSE OF YOUR PAIN?PLEASE DETAIL BELOWINDICATE THE AREAS OF YOUR BODY WHERE YOU FEEL PAIN AND NUMBNESS, TINGLING OR PINS AND NEEDLESIndicate the areas in your body where you feel numbness, tingling or pins and needles with XXIndicate the areas in your body where you feel pain with /// NECK (L)NECK (R)CHEST (L)CHEST (R)WAIST (L)WAIST (R)HIPS (L)HIPS (R)LEGS (L)LEGS (R)HEAD (L)HEAD (R)UPPER BACK (L)UPPER BACK (R)BACK (L)BACK (R)ARMS (L)ARMS (R)BUTTOCKS (L)BUTTOCKS (R)LEGS (L)LEGS (R)WHERE IS YOUR PAIN WORST?* NECK BACK HEADACHES BUTTOCKS DOWN THE LEG'S DOWN ARMS UPPER BACKIS YOUR PAIN GETTING* WORSE BETTER UNCHANGEDIS YOUR PAIN* ALWAYS THERE COMES AND GO OVER THE DAYDO YOU GET NUMBNESS OR TINGLING IN YOUR LEGS?* YES NODO YOU GET NUMBNESS OR TINGLING IN YOUR ARMS?* YES NOWHAT ACTIVITIES MAKE THE PAIN WORSE? BENDING FORWARD BENDING BACKWARD LYING ON SIDE _ L_ R LYING ON BACK LYING ON STOMACH SLEEPING SITTING _____ MINS STANDING _____ MINS WALKING _____ MINS DRIVING _____ MINS LIFTING COUGHING SNEEZING JARRING/VIBRATION TWISTING EXERCISE OTHEROTHERWHAT REDUCES THE PAIN? SITTING STANDING WALKING LYING DOWN Position MASSAGE PHYSIOTHERAPY PAIN PILLS ANTI-INFLAMMATORIES OTHERLYING DOWN PositionOTHERWHAT OTHER TREATMENTS HAVE YOU HAD? OSTEOPATHY MYOTHERAPY SUPERVISED EXERCISE ACUPUNCTURE OTHER CORSET/BRACE CHIROPRACTIC TREATMENT CLINICAL PSYCHOLOGISTDETAILS OF TREATMENTCLINIC AND NAME OF TREATING THERAPISTHAVE YOU HAD IMAGING OF YOUR SPINE COMPLETED FOR THIS EPISODE OF PAIN XRAY CT SCAN MRI BONE SCANWHAT IMAGING COMPANY WAS USED AND LOCATION?HAVE YOU HAD BACK/NECK PAIN BEFORE THE CURRENT EPISODE YES NOAPPROX DATE/YEAR 1ST EPISODEHOW MANY EPISODES OF PAIN A YEAR?ARE THE EPISODES CLOSER TOGETHER?* YES NOIS THE INTENSITY OF EPISODES INCREASING?* YES NOHAVE YOU EVER HAD BACK OR NECK SURGERY (OPERATION) YES NOWHAT WAS THE OPERATIONDATE OF OPERATION MM slash DD slash YYYY SURGEONHOSPITALAPART FROM SPINAL OPERATIONS, LIST OTHER OPERATIONS YOU HAVE HAD?LIST OTHER SPECIALISTS YOU HAVE SEEN FOR THIS CONDITIONDO YOU EXERCISE ON A REGULAR BASIS?* YES NOHOW FREQUENTLY?WHAT EXERCISE/S DO YOU DO?DO YOU SMOKE?* YES NOHOW LONG HAVE YOU SMOKED?HAVE YOU EVER SMOKED?* YES NOHOW MANY PER DAY?WHEN DID YOU QUIT?DO YOU DRINK ALCOHOL?* YES NOHOW MANY DRINKS PER DAY?OR PER WEEK?ARE YOU INVOLVED IN ANY LITIGATION OR COMPENSATION PROCESSES DUE TO YOUR BACK CONDITION?* YES NOPLEASE LIST THE CURRENT MEDICINES AND PAIN SUBSTANCES YOU ARE USING (PRESCRIPTION AND OTHER DRUGS)ARE YOU CURRENTLY TAKING OR USING CORTISONE?* YES NO(PREDNISOLONE OR SIMILAR)HAVE YOU BEEN DIAGNOSED WITH CANCER? YES NODETAILSHAVE YOU EXPERIENCED: UNINTENTIONAL WEIGHT LOSS SWEATS FEVERSDETAILSDO YOU HAVE ANY OF THE FOLLOWING MEDICAL HEALTH PROBLEMS? STOMACH PROBLEMS, ULCERS ETC HEART PROBLEMS ANAEMIA DIABETES ASTHMA CHRONIC AIRWAYS DISEASE ARTHRITIS CHEST PAIN TB CANCER KIDNEY DISEASE HEPATITIS HIGH BLOOD PRESSURE PACEMAKER COVID-19 DEPRESSION SLEEP APNOEA STROKE BLEEDING TENDENCIES OTHER CONDITIONSOTHER CONDITIONSLIST ANY MEDICAL CONDITIONS YOU HAVE HAD IN THE PASTDO YOU HAVE BOWEL OR BLADDER PROBLEMS? YES NODO YOU HAVE LOSS OF CONTROL WITH COUGH/SNEEZE/LIFTING/JUMPING? YES NOOTHER DETAILSHAVE THEY DEVELOPED SINCE THE ONSET OF YOUR PAIN?* YES NOIS YOUR PAIN WORSE WHEN WAKING IN THE MORNING?* YES NODO YOU SNORE?* YES NODO YOU HAVE ANY ALLERGIES (EG DRUGS, ADHESIVES SUCH AS BANDAIDS OR TAPE OR FOOD)ADDITIONAL INFORMATIONPlease score your pain – Neck and ArmPlease CLICK ON THE LINE on the bottom two scales to indicate the AVERAGE level of pain you have experienced over the last week where 0 is no pain and 10 is worst pain imaginable.NECK PAIN: NECK DOWN TO TIP OF SHOULDERARM PAIN: BELOW THE TIP OF SHOULDEROswestry 2.0: For Patients with Lower Spine and Leg PainThis questionnaire has been designed to give us information about how your back or leg pain is affecting your ability to manage in every day life. Please answer every section and mark only one box in each section that best applies to you – we realise you may consider that two or more statements in any one section apply but please tick the one that most clearly describes your problem.Section 1 — Pain Intensity I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the momentSection 2 — Personal Care (Washing, Dressing etc) I can look after myself without causing extra pain I can look after myself normally but it is very painful It is painful to look after myself and I am slow and careful I need some help, but can manage most of my personal care I need help every day in most aspects of self care I do not get dressed, I wash with difficulty and I stay in bedSection 3 — Lifting I can lift heavy weights without extra pain I can lift heavy weights but it gives me extra pain Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, ie on a table Pain prevents me lifting heavy weights off the floor, but I can manage to lift medium weights if they are positioned conveniently I can only lift very light weights I cannot lift or carry anything at allSection 4 — Walking Pain doss not prevent me walking any distance Pain prevents me walking more than 2 kilometres Pain prevents me walking more than 1 kilometre Pain prevents me walking more than 500 metres I can only walk using a stick or crutches I am in bed most of the time and I have to crawl to the toiletSection 5 — Sitting I can sit in any chair as long as I like I can only sit in my favourite chair as long as I like Pain prevents me sitting more than 1 hour Pain prevents me sitting more than 30 minutes Pain prevents me sitting more than 10 minutes Pain prevents me from sitting at allSection 6 — Standing I can stand as long as I want without extra pain I can stand as long as I want but it gives me extra pain Pain prevents me from standing more than 1 hour Pain prevents me from standing more than 30 mins Pain prevents me from standing more than 10 mins Pain prevents me from standing at allSection 7 — Sleeping My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain I have less than 6 hours sleep Because of pain I have less than 4 hours sleep Because of pain I have less than 2 hours sleep Pain prevents me from sleeping at allSection 8 — Sex Life (If applicable) My sex life is normal and causes no extra pain My sex life is normal but causes some extra pain My sex life is nearly normal but Is very painful My sex life is severely restricted by pain My sex life is nearly absent because of pain Pain prevents any sex life at allSection 9 — Social Life 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, eg sport Pain has restricted my sociaI life and I do not go out as often Pain has restricted my social life at home I have no social life because of painSection 10 — Travelling I can travel anywhere without pain I can travel anywhere but it gives me extra pain Pain is bad but I manage journeys more than 2 hours Pain restricts me to journeys of less than 1 hour Pain restricts me to short necessary journeys less than 30 minutes Pain prevents me from traveling except to receive treatmentNeck Disability Index – Initial: For Patients with Upper Spine PainThis questionnaire has been designed to give us information about how your neck pain is affecting your ability to manage in every day life. Please answer every section and mark only one box in each section that best applies to you – we realise you may consider that two or more statements in any one section apply but please tick the one that most clearly describes your problem.Section 1 — Pain Intensity I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the momentSection 2 — Personal Care (Washing, Dressing etc) I can look after myself without causing extra pain I can look after myself normally but it is very painful It is painful to look after myself and I am slow and careful I need some help, but can manage most of my personal care I need help every day in most aspects of self care I do not get dressed, I wash with difficulty and stay in bedSection 3 — Lifting I can lift heavy weights without extra pain I can lift heavy weights but it gives extra pain Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, ie on a table Pain prevents me lifting heavy weights off the floor, but I can manage light to medium weights if they are positioned conveniently I can only lift very light weights I cannot lift or carry anythingSection 4 — Reading I can read as much as I want to with no pain in my neck I can read as much as I want to with slight pain in my neck I can read as much as I want with moderate pain in my neck I can’t read as much as I want because of moderate pain in my neck I can hardly read at all because of severe pain in my neck I cannot read at allSection 5 — Headaches I have no headaches at all I have slight headaches, which come infrequently I have moderate headaches, which come infrequently I have moderate headaches, which come frequently I have severe headaches, which come frequently I have headaches almost all the timeSection 6 — Concentration I can concentrate fully when I want to with no difficulty I can concentrate fully when I want to with slight difficulty I have a fair degree of difficulty in concentrating when I want to I have a lot of difficulty in concentrating when I want to I have a great deal of difficulty in concentrating when I want to I cannot concentrate at allSection 7 — Work I can do as much work as I want to I can only do my usual work, but no more I can do most of my usual work, but no more I cannot do my usual work I can hardly do any work at all I can’t do any work at allSection 8 — Driving I can drive my car without any neck pain I can drive my car as long as I want with slight pain in my neck I can drive my car as long as I want with moderate pain in my neck I can’t drive my car as long as I want because of moderate pain in my neck I can hardly drive at all because of severe pain in my neck I can’t drive my car at allSection 9 — Sleeping I have no trouble sleeping My sleep is slightly disturbed (less than 1 hr sleepless) My sleep is mildly disturbed (1-2 hrs sleepless) My sleep is moderately disturbed (2-3 hrs sleepless) My sleep is greatly disturbed (3-5 hrs sleepless) My sleep is completely disturbed (5-7 hrs sleepless)Section 10 — Recreation I am able to engage in all my recreation activities with no neck pain at all I am able to engage in all my recreation activities, with some pain in my neck I am able to engage in most, but not all of my usual recreation activities because of pain in my neck I am able to engage in a few of my usual recreation activities because of pain in my neck I can hardly do any recreation activities because of pain in my neck I can’t do any recreation activities at allDASS21Please read each statement and select a number 0, 1, 2, or 3 which indicates how much the statement applied to you over this past week. There are no right or wrong answers. Do not spend too much time on any statement.The rating scale is as follows:0 Did not apply to me at all1 Applied to me to some degree, or some of the time2 Applied to me a considerable degree, or a good part of the time3 Applied to me very much, or most of the timeI found it hard to wind downI was aware of dryness in my mouthI couldn’t seem to experience any positive feeling at allI experienced breathing difficulty (eg excessively rapid breathing, breathlessness in the absence of physical exertion)I found it difficult to work up the initiative to do thingsI tended to over-react to situationsI experienced trembling (eg in the hands)I felt I was using a lot of nervous energyI was worried about situations in which I might panic and make a fool of myselfI felt that I had nothing to look forward toI found myself getting agitatedI found it difficult to relaxI felt down-hearted and blueI was intolerant of anything that kept me from getting on with what I was doingI felt I was close to panicI was unable to become enthusiastic about anythingI feIt I wasn’t worth much as a personI felt I was rather touchyI was aware of the action of my heart in the absence of physical exertion (eg sense of heart rate increase, heart missing a beat)I felt scared without any good reasonI felt that life was meaninglessTAMPAPlease select one number for each question that most closely relates to how you feel about the statements below.The rating scale is as follows:1 Strongly disagree2 Disagree3 Agree4 Strongly agreeI’m afraid that I might injure myself if I exerciseIf I were to try to overcome it, my pain would increaseMy body is telling me I have something dangerously wrongMy pain would probably be relieved if I were to exercisePeople aren’t taking my medical condition seriously enoughMy accident has put my body at risk for the rest of my lifePain always means I have injured my bodyJust because something aggravates my pain does not mean it is dangerousI am afraid that I might injure myself accidentallyI am careful to not make any unnecessary movements is the safest thing I can do(to prevent my pain from worsening)I wouldn’t have this much pain if there weren’t something potentially dangerous going on in my bodyAlthough my condition is painful, I would be better off if I were physically activePain lets me know when to stop exercising so that I don’t injure myselfIt’s really not safe for a person with a condition like mine to be physically activeI can’t do all the things normal people do because it’s too easy for me to get injuredEven though something is causing me a lot of pain, I don’t think it’s actually dangerousNo one should have to exercise when he/she is in pain