SAN DIEGO SPINE & REHAB
NEW PATIENT QUESTIONNAIRE


Click Here to print a blank form
or
Fill out the form below. You can save it and email it to us or print it out and bring it with you to our office.

Email for MIssion Valley Office: KristinSutton@SDSR.com

Email for Oceanside Office: KristinSutton@SDSR.com

 

TODAY’S DATE
PT. NUMBER
PATIENT’S DEMOGRAPHICS:
PATIENT’S FIRST NAME LAST NAME AGE
DATE OF BIRTH SOCIAL SECURITY # SEX: Male Female
HOME PHONE CELL or WORK PHONE E-MAIL
HOME ADDRESS
CITY STATE ZIP
IF PATIENT IS A MINOR, PARENT OR LEGAL GUARDIAN
PARENT/GUARDIAN DOB PARENT/GUARDIAN SS #
EMERGENCY CONTACT INFORMATION:
EMERGENCY CONTACT NAME RELATION TO PATIENT
PRIMARY PHONE # ALTERNATE PHONE #
EMPLOYMENT INFORMATION
COMPANY PHONE
ADDRESS
CITY STATE ZIP
INSURANCE INFORMATION:
INSURANCE COMPANY NAME
ADDRESS
CITY STATE ZIP
PHONE EXTENSION
MEMBER ID # GROUP #
PERSONAL (PRIMARY) PHYSICIAN PHONE
ADDRESS
HOW WERE YOU REFERRED TO OUR OFFICE?
REFERRING PHYSICIAN PHONE
ADDRESS
PHARMACY: NAME ADDRESS
PHONE       FAX
SDSR
HEALTH HISTORY
PATIENT NAME
DATE
WHERE IS YOUR PAIN LOCATED? (Be Specific and Label Worst Area) PATIENT TO DRAW/MARK ALL THAT APPLY
  • Head
  • L
  • R

  • Neck
  • L
  • R

  • Upper Back
  • L
  • R

  • Mid Back
  • L
  • R

  • Low Back
  • L
  • R

  • Shoulder
  • L
  • R

  • Elbow
  • L
  • R

  • Wrist
  • L
  • R

  • Hand
  • L
  • R

  • Buttock
  • L
  • R

  • Leg (thigh)
  • L
  • R

  • Knee
  • L
  • R

  • Calf
  • L
  • R

  • Foot
  • L
  • R



DATE OF INJURY
HOW DID YOU GET HURT? (Please give details including dates and places)
WHAT BODY PARTS DID YOU HURT?
HAVE YOU EVER HURT THIS BODY PART BEFORE? Yes No HOW:
WHO FIRST TREATED YOU, AND WHERE?
WHO HAS TREATED YOU SINCE?
CHARACTER OF YOUR PAIN PLEASE MARK ALL THAT APPLY & THE LOCATION IT OCCURS:
CONTINUOUS (ALL DAY): DULL SHARP ACHING THROBBING SHOOTING RADIATING BURNING TINGLING NUMB HOT
WHERE:
INTERMITTENT (ON & OFF) DULL SHARP ACHING THROBBING SHOOTING RADIATING BURNING TINGLING NUMB HOT
WHERE:
OCCASIONALLY: DULL SHARP ACHING THROBBING SHOOTING RADIATING BURNING TINGLING NUMB HOT
WHERE:
WHAT MAKES YOUR PAIN WORSE: Sitting Standing Bending: Forward or Back Walking Lying Flat Driving
How Long Can You Now: Sit min. Stand min. Walk min. Run min.
WHAT MAKES YOUR PAIN BETTER: Lying Down Walking Ice Heat PT CHIRO Massage Medications
Other
DOES THE PAIN LIMITS YOUR ACTIVITIES OF DAILY LIVING? YES NO
IF YES, WHAT PERCENT OF THE DAY? 10% 25% 50% 75% 100%
SDSR
HEALTH HISTORY CONT.
WHAT CAN YOU NOT DO OR HAVE DIFFICULTY DOING NOW?
Self Care: Showering Brushing Hair Brushing Teeth Putting on cloths
Communication: Speaking Writing Typing Talking on Phone
Physical Activity: Walking stairs Walking Standing Sitting Exercise
Sensory Function: Hearing Seeing Feeling things Tasting Smelling
Hand Activity: Lifting Pulling/Pushing Grasping Turning pages Holding things
Travel: Driving a car Turning head to look Pain with sitting Pain with bumps in the road
DOES THE PAIN AFFECT YOUR SLEEP? YES NO
IF YES, PLEASE DESCRIBE YOUR SLEEPING HABITS:
DO YOU FEEL DEPRESSED? YES NO DID YOU FEEL DEPRESSED BEFORE YOUR INJURY? YES NO
DO YOU HAVE ANY THOUGHTS OF DOING HARM TO YOURSELF OR OTHERS? YES NO
WHAT TREATMENTS HAVE YOU HAD?
  • DATES DONE
  • DID THIS HELP?
  • PHYSICAL THERAPY
  • YES NO

  • CHIROPRACTIC THERAPY
  • YES NO

  • HEAT TREATMENT
  • YES NO

  • ICE TREATMENT
  • YES NO

  • ACUPUNCTURE
  • YES NO

  • EPIDURAL INJECTIONS
  • YES NO

  • FACET INJECTIONS
  • YES NO

  • TRIGGER POINT INJECTIONS
  • YES NO

  • JOINT INJECTIONS
  • YES NO

  • PSYCHOLOGISTS
  • YES NO

  • NAME
  • PHONE
HAVE YOU HAD ANY RECENT X-RAYS MRI’s CT’s
IF SO, WHAT DID THEY SHOW?
MEDICATIONS: PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING:
  • MEDICATION
  • DOSE
  • TABLETS PER DAY
  • PRESCRIBED BY (Dr.)
DO YOU TAKE BLOOD THINNERS? NO YES (DRUG NAME AND DOSE)
ALLERGIES/INTOLERANCE: DO YOU HAVE ANY ALLERGIES TO MEDICATIONS ? NO YES
LIST DRUGS AND TYPE OF REACTIONS

PAST MEDICAL PROBLEMS HISTORY: (Mark all conditions you have or had in the past)
HEART ATTACK ASTHMA PROSTATE PROBLEM ARTHRITIS
HEART DISEASE DIABETES STOMACH ULCER INTESTINAL PROBLEMS
ANGINA (CHEST PAIN) CANCER PREGNANCY C-SECTIONS
STROKE LIVER PROBLEMS SEIZURES OTHERS:
HIGH BLOOD PRESSURE TUBERCULOSIS KIDNEY PROBLEMS
DEPRESSION LUNG PROBLEMS BLEEDING PROBLEMS PREVIOUS INJURIES:
DATE
THYROID PROBLEMS ANXIETY SLEEPING DIFFICULTIES
WHAT BODY PART?

SURGERIES YOU HAVE HAD:
  • SURGERY
  • DATE (Most Recent First)
  • PHYSICIAN
  • DID IT HELP?
HOSPITALIZATIONS YOU HAVE HAD:
  • DATE (Most Recent First)
  • REASON
  • HOSPITAL (Name and Location)
FAMILY HISTORY: (i.e., Joint/Back Problems, Arthritis, Cancer, Lung Problems, Heart Disease, etc.)
Please List conditions on the lines provided
  • Mother:
  • Alive Deceased

  • Father:
  • Alive Deceased

  • Children:
  • Alive Deceased

  • Siblings:
  • Alive Deceased

  • Uncle:
  • Alive Deceased

  • Aunt:
  • Alive Deceased

  • Grandfather:
  • Alive Deceased

  • Grandmother:
  • Alive Deceased

SOCIAL HISTORY:
MARITAL STATUS: MARRIED SINGLE DIVORCED SEPERATED
CHILDREN?       HOW MANY?       HOW MANY LIVE WITH YOU?
EDUCATION:       LAST GRADE COMPLETED:
TOBACCO – PACKS/DAY PRESENTLY or years SINCE YOU QUIT
ALCOHOL – DRINKS / DAY or WEEK WHAT?


ACTIVITIES / EXERCISE YOU DID PRIOR TO YOUR INJURY
OCCUPATION
BRIEFLY DESCRIBE WHAT YOU DO AT WORK:
STREET DRUGS or PAST DRUG DEPENDENCY? YES NO WHAT?
ROS - DO YOU HAVE ANY OF THE FOLLOWING? ( Mark all that apply )
CHEST PAIN OR PRESSURE EASY BRUISING RECENT BLEEDING PROBLEMS WITH URINATION
SHORTNESS OF BREATH ABDOMINAL PAIN CONSTIPATION INTOLERANT TO COLD/HEAT
COUGH DIZZINESS DIARRHEA NAUSEA
ANKLE SWELLING FAINTING VISION CHANGES WEAKNESS
OTHER
INITIAL VITAL SIGNS:
Height Weight
PAIN LEVEL AT ITS BEST (when at rest) 1 2 3 4 5 6 7 8 9 10
PAIN LEVEL AT ITS WORST (when active) 1 2 3 4 5 6 7 8 9 10
MILD
MODERATE
SEVERE


TO OUR PATIENTS:
I HEREBY AUTHORIZE AND ASSIGN TO SAN DIEGO SPINE & REHAB / DIRECT HEALTH MEDICAL CENTER AND THEIR DOCTORS MY RIGHTS TO RECEIVE PAYMENTS FROM NEGLIGENT PARTIES OR FROM INSURANCE COMPANIES. I AUTHORIZE SAN DIEGO SPINE & REHAB / DIRECT HEALTH MEDICAL CENTER TO RELEASE ANY INFORMATION TO ANY INSURANCE CARRIER, ADJUSTER, ATTORNEY, OR GOVERNMENT AGENCY THAT WILL ASSIST IN THE PAYMENT FOR SERVICES RENDERED BY SAN DIEGO SPINE & REHAB / DIRECT HEALTH MEDICAL CENTER AND ITS DOCTORS.

PATIENT’S SIGNATURE
DATE


MULTIPLE REGION FUNCTIONAL CAPACITY
Name: Date Age:
Patient: Fill out sections 1 to 10. In each category, check one box that best applies your current condition.
1. CURRENT PAIN INTESNITY
I have no pain currently
I have occasionally pain which mildly disturbs me at work and home.
I have frequent annoying pain with an occasional pain that slow me down
I have frequent moderate level pain and occasional severe pain that stop me from performing more strenuous activities.
I have some degree of pain at all times, with frequent bouts of severe pain which prevent my performing many normal activities
I have pain all of the time, mostly severe, which I am unable to do most activities for myself. Medications don’t help.
2. WORK ABILITY
I am able to currently work full time with no pain.
I work full time and have slight (annoying) symptoms which occasionally may slow me down thus taking slightly longer.
I work full time. My work output quality and/or quantity are reduced 10-20%. Symptoms vary from a slight to moderate levels which cause intermittent halting. I require assistance occasionally at work.
I am able to work part time. I am not able to work at normal pace beyond two hours and at slower pace beyond four hours. My performance output quality and/or quantity are reduced 30 to 60%.
I am able to work part time. I am not able to work at normal pace for more than 30-60 minutes at a time. I can work at a slower pace beyond two hours. My ability to perform in output are reduced by over 70%.
I am not able to work at normal or slower pace at all. Job quality and/or quantity are reduced more than 90%. Unable to work on part-time status even with a flexible work schedule.
3. SPORTS, HOBBIES, AND SOCIAL ACTIVITIES
I can perform normal sports, hobby activities, and social activities with my friends, family, or business acquaintances.
My sports, hobby, and social life are normal but pain slows me down occasionally.
Pain or other symptoms limits my more energetic or competitive sports, hobby activities, social activities such as dancing and running.
Severe pain or other symptoms limits moderate energetic sports, hobby, and social activity. I do not go out as often.
Pain or other symptoms limits me to only minimal sports, hobby, and social activity. I usually stay at home.
Unable to participate in any sports, hobby, or social activity due to pain.
4. HOME ACTIVITIES
I can perform normal home activities such as vacuuming, cooking, cleaning, mowing lawn, doing laundry with no pain.
I am able to do all normal home duties but pain slows me down occasionally with very strenuous activities.
Pain prohibits very strenuous home activities. I am able to do lighter to moderate strenuous level home activities.
Severe pain or other symptoms limits moderate and strenuous home activities. I need help doing some activities.
I am able to do only light home activities. I am unable to vacuum floor, do dishes, sweep, mop, and laundry.
I am unable to do any home activities due to pain or other symptoms. I need help putting on clothes and taking bath.
5. SLEEPING
I normally have no difficulty sleeping due to pain or other symptoms.
I have occasional difficulty sleeping due to pain or other symptoms waking up at night resulting in 30 minutes loss of sleep.
I have occasional difficulty sleeping due to pain or other symptoms. I loose 10-15% of normal sleeping hours a night.
I have occasional difficulty sleeping due to pain or other symptoms. I am restless most of the night. I lose 25% of hours of sleep a night.
My sleeping hours are reduced about 50%. I usually need medications to sleep well.
I have no normal sleeping hours. I am never able to sleep more than 2-3 hours without heavy medication. I never feel rested.
6. SITTING
I can sit at my desk or drive my car normally with no pain.
I can sit at my desk or drive my car with occasional annoying pain. I need to take breaks on long trips.
Sitting or driving causes frequent annoying pain. Pain becomes severe if sitting for more than 2 hours where I need to change position.
I can sit or drive for 3-4 hours but I need frequent breaks to change my body position. Unable to sit constantly over 1 hour.
I cannot sit or drive for more than 30 minutes at a time due to pain severity.
I cannot sit at my desk, chair at home, or drive my car at any time due to pain severity.
7. UPPER BODY FUNCTION (Neck and arms)
I am able to use my neck, shoulders, arms and hands in all normal activities with no pain.
I am able to use my neck, shoulders, arms and hands in all normal activities with occasional annoying pain.
I am able to lift and move my head and neck, lift arms over my head, reach over my head, carry objects, grip objects with my hand. I have occasional pain when lifting heavy objects over my head which cause me to stop. Occasionally will have difficulty feeling or gripping objects with my hands due to either weakness or numbness. I am limited to light to moderate weights in my hands.
I am able to lift my arms up to the height of my shoulder for short periods of time but not over my head, carry light to moderate weight objects, grip objects with my hands. I get occasional pain when lifting heavy objects over my head. Occasionally will have difficulty typing, feeling, or gripping objects with my hands due to weakness or numbness. I drop objects 2-3 times a week. I have to use 2 hands for some activities where I could it with one hand before. I am limited to moderate weights.
I am able carry and grip light objects only. I get frequent pain when lifting any objects over my waist and sometimes am unable to lift to the height of my shoulder. I am unable to lift my arms to the height of my shoulder and lift over my head. I frequently have difficulty feeling or gripping objects with my hands due to either weakness or numbness. I drop objects daily unless I am very careful. I have to use two hands for most activities where I could it with one hand before. I have frequent difficulty typing, using the computer, and writing letters. I am limited to light weights. I have lost 75% of hand lifting ability.
I am able to lift my arms to the level of my shoulders only and just lifting my arms above my waist causes severe pain. I am unable to lift any object over the height of my waist. Every time I lift my arms up I get severe pain in my neck, shoulders, or arm and I have to lower my arm or arms immediately. I am unable to write letters. I am unable to lift 5 pounds in my hands.
8. LOWER BODY FUNCTION (Low back and legs)
I can sit, drive, stand, squat, stoop, walk, bend my knees, use my feet, and lift normal heavy weights with no low back/leg pain.
I can sit, drive, stand, squat, stoop, walk, bend my knees, use my feet, and lift normal heavy weights with occasional annoyance of mild pain. I can do all of these activities but slower if demands are high.
Moderate levels of low back/leg pain happen if I do prolonged or repeated sitting, driving, standing, stooping, walking, or bending. I can lift heavy objects of positioned properly. Pain limits me to walking ½ mile. Unable to stand for more than 45 minutes at a time. Repeated stooping or bending more than 20 minutes cause me to slow down.
Moderate to severe levels of low back/leg pain happen if I do prolonged or repeated sitting, driving, standing, stooping, walking, or bending. I can’t lift heavy objects at all and am able to lift moderately heavy objects (1/4 my body weight) if properly positioned. Pain limits me to walking ¼ mile. Unable to stand for more than 30 minutes at a time.
I experiences severe levels of pain if I do short term sitting, driving, standing, stopping, walking or bending. I can’t lift moderate or heavy objects at all and am able to lift light objects only (10-15lbs). Need lumber belt support and/or cane for support to walk. Pain limits me to walking to one block. Unable to stand for more than 10 minutes at a time.
I experience severe levels of pain if I do sitting, driving, standing, stopping, walking or bending. I am able to walk only with use of cane, crutches or wheelchair. I need to lie down frequently to relieve pain. I am unable to lift or carry any object over five pounds. I need lumbar belt support and/or cane for support to move about in my home. During the daytime I lie down 3-4 hours.
9. HEADACHES
I have no headaches normally
I have headaches occasionally which only annoy me at work or at home.
I have occasional headaches which are intense enough to slow me down at work and home occasionally.
I have occasional headaches which causes me to stop and rest for short periods of time frequently
I have frequent headaches which stops all of my activity. I frequently lose time at work or have delays in work production due to pain.
I have frequent headaches which cause me not being able to go to work, school, home, or participate in recreational activities.
10. MENTAL ABILITY
My memory and mental function are normal. I have no difficulty with work or home demands.
I am able to perform most mental activities and am able to function at work, home, and in society. I have occasional slight difficulty with complex tasks, memory, and math.
I am able to functions normally in most work, home, and society activities. Complex tasks, multiple tasks, and intense concentration tasks are difficult, often resulting in mistakes. I have noticed about a 10-25% memory loss and job performance decline recently.
I am not able to handle difficult or complex tasks. I have notable memory loss and difficulty making decisions. My friends, family, and I have noticed recent personality changes., It takes much linger to do work and home tasks. I can handle one simple task at a time. I have to write down my daily tasks to remember. My job performance ratings are poor. I have noticed about 26-50% memory loss and job performance decline recently.
I am able to handle only simple tasks one at a time. Unable to keep full time job. My job performance ratings are poor. My reaction times have slowed down a lot. I have notice about a 52-75% memory loss and job performance declined recently.
I am unable to hold any job at all. I am unable to balance my checkbook and need help. I am unable to shop without a shopping list. I have severe performance difficulties. I am unable to remember instructions.
TOTAL SCORE (1-10) x2=
Recommendations:
Reviewed By MD PA             Date Reviewed:


NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
San Diego Spine and Rehab, Inc.
Oceanside, CA
3772 Mission Ave., Suite 122
Oceanside, CA 92058
760-630-8400
San Diego,CA
9610 Granite Ridge Drive, Suite C
San Diego, CA 92123
858-573-0550
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPPA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers
  • Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Patient Name:
Relationship to Patient:
Signature:
Date

OFFICE USE ONLY
I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:
Date Initials: Reason:
San Diego Spine & Rehab Inc.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLESE REVIEW IT CAREFULLY
The Health Insurance Portability & Accountability Act of 1996 (“HIPPA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPPA” provides penalties for covered entities that misuse personal health information.
As required by “HIPPA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.
  • Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.
  • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
  • Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions on relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
  • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are however, not required to agree to requested restriction.
  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of this notice from us upon request.
We are required by to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
Please contact us for more information:
For more information about HIPPA or to file a complaint:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257
Toll Free: 1-877-696-6775
Please PRINT the form by clicking the print button below. This will create a printable PDF File. You can print it out or email it to us. Please find the correct email address location below


  • SAN DIEGO/ MISSION VALLEY
    9610 Granit Ridge Dr. #C
    San Diego, CA 92123
    Email for MIssion Valley Office:
  • LeighWatts@SDSR.com
  • OCEANSIDE, CA
    3772 Mission Ave, Ste 122
    Oceanside, CA 92058
    Email for Oceanside Office:
  • KristinSutton@SDSR.com

    BACK TO TOP After clicking PRINT, please wait a moment while your application is being populated into a printable PDF file. Once the PDF file is in view, you can right click the page to SAVE AS. Please email it to the proper office location or fill free to print the form out and bring it into our office. Thanks!