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Microsoft word - jph-new patient paperwork.doc

John Hammerstein, MD

PATIENT NAME: _________________________________
*Due to the nature of our specialty there may be patients that require additional time than was allowed for their
appointment. This may lead to extended wait times. We appreciate your patience in allowing us to provide
optimum care to all our patients.

Patient Medical History

History of problem for which you are seeing us
Duration of symptoms _____________________________________________________ How did problem start? No injury/event At work (date________) Home/leisure. Briefly describe events: ____________________________________________________ If you have pain or numbness: Mark “X” on the body part(s) with pain.
Mark “O” on body part(s) with numbness.
Pain Scale Please circle appropriate number: 1 = no pain, 10 = severe pain.
Typically, pain level is: 1-----2-----3----4----5----6----7----8----9----10 At its worst, my pain is: 1-----2-----3----4----5----6----7----8----9----10 At its best, my pain level is: 1-----2-----3----4----5----6----7----8----9----10 Character of pain: Burning Stabbing Deep ache Frequency: Constant Intermittent Rare Improvement? (since onset) Worsened Improved Stayed the same Weakness: Yes No
Diagnostic History
X-rays Yes No Date/Location _____________________
MRI Yes No Date/Location _____________________
CT scan Yes No Date/Location _____________________
Bone scan Yes No Date/Location _____________________
EMG Yes No Date/Location _____________________
Other Yes No Date/Location _____________________

Allergies _________________________________________________________________________
What is your reaction to this allergy? _________________________________________________
Medications Example: Received: Did it work?
Anti-inflammatory Naprosyn, Ibuprofen Y – N Y – N
Muscle relaxer Soma, Flexeril, Skelaxin Y – N Y – N
Pain medication Tylenol w/codeine, Vicodin,
Darvocet, Percocet Y – N Y – N
Oral Steroid Medrol Dose Pak, Prednisone Y – N Y – N
Nerve medication Lyrica, Neurontin Y – N Y – N
Treatments Received: Did it help?
Have you seen another spine care specialist for this problem? Yes No If yes, Date_______________ Name of Physician:______________________ Recommendations/treatments: ___________________________________________ Legal advice
Do you have an attorney regarding this injury/problem? Yes No If yes, please list the attorney’s name: _____________________________________ Past Medical History (circle all that you have experienced)
Other problems: __________________________________________________________________________

Work Status
Number of years at current job: _______ Are you currently employed? Yes No
If so: Regular duty Modified duty Working hrs / week __________
Where are you currently employed? ____________________________________________________________
What is your current occupation? ______________________________________________________________
What are your restrictions? _____________________________________________________________
Who wrote the restrictions? _____________________________________________________________
Review of Systems
(In the past month, have you experienced any of the following? Please check each box.)
(If you have any of these symptoms, please notify your family doctor.)

HEENT Integumentary

General Neurologic


(Please list all the medications you are currently taking.)
Dose & times/day
Dose & times/day

Do you:
Smoke: yes no _____Packs/day _____ # of YRS.
Past smoker? yes no _____Packs/day _____ # of YRS.
Drink alcohol: yes no _____ # drinks/week. Smoking and chewing tobacco is a leading risk factor in the development of degenerative disc disease. A disc is the shock absorber between the bones in your spine. When the disc starts to wear out it loses some of its ability to provide a "cushion" between bones. This allows for a greater risk of rupture. The discs already have a poor blood supply and when you smoke or use tobacco the blood vessels constrict (narrow) and the oxygen supply is lowered even more. Smokers also introduce carbon monoxide into the blood stream which can inhibit the discs' ability to absorb needed nutrients from the blood. This leads to dehydrated discs and eventually degenerative disc disease. If your spinal condition deteriorates enough to need a fusion surgery you will need to stop smoking or using tobacco. Nicotine is a bone toxin and can slow down new bone growth. The failure rate for many fusions can be 3 to 4 times higher for someone using tobacco. Many times you cannot have your surgery until you have been able to stop smoking or using tobacco. There are a number of different options available to assist in smoking or tobacco cessation. Please let us know when you are ready to quit using tobacco. If you are a current smoker, please initial and date here stating that you have read and understand the above smoking cessation recommendation:
Family History

State of health
If deceased, age and cause of death
________________________________________________________________ Mother ________________________________________________________________ Brothers ________________________________________________________________ Sisters ________________________________________________________________ ________________________________________________________________ ________________________________________________________________



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