Cervical Spine Intake

Cervical Spine Intake

Patient Name

Date of Birth

MM slash DD slash YYYY

Job

Work Status

Working

Not Working

Disabled

Retired

Mode of Transportation to Appointment

Walked

Mode of Transportation to Appointment

Private

Self

Family or Friend

Taxi

Public

Access-a-Ride

Bus

Train

Subway

Hand dominance

Ambidextrous

Axial Symptoms

Neck Pain

Worse with:

Bending

Twisting

Lifting

Driving over potholes

Valsalva

Radiates up into back and top of head (i.e. causes headaches)

Radiates into upper back between shoulder blades

Axial Symptoms:

Neck Stiffness

Bad in the morning, eases up with stretching & a hot shower

Axial Symptoms:

Head feels heavy & as though it wants to drop off neck

Radicular Symptoms:

Electrical/shock-like pain radiating into any of these regions? (select all that apply)

Radicular Symptoms:

Numbness in any of these regions? (select all that apply)

Radicular Symptoms:

Tingling/pins and needles in any of these regions? (select all that apply)

Radicular Symptoms:

Electrical feelings in arms/hands worse with coughing, sneezing, pushing down to move bowels, etc.

Radicular Symptoms:

Upper extremity weakness? (select all that apply):

Upper extremity weakness? (r L):

Upper extremity weakness? (select all that apply):

Weakness with grip strength (i.e. opening jars)

Unable to lift and/or carry

Dropping lightweight, common household objects (i.e. cup of coffee, cell phone, remote control)

Myelopathy Symptoms:

Fine motor incoordination with hands (i.e. buttoning shirts, clasping watch/jewelry, placing butterflies on ear rings, spilling sugar when stirring tea/coffee)

Balance disorder (i.e. unable to walk a straight line; unsteady when descending stairs, needing to clutch/rely on handrail)

Has actually fallen to the ground due to balance issues

Myelopathy Symptoms:

Handwriting and/or signature have worsened from baseline

Increased urinary frequency

Increased urinary incontinence

Wearing pads/protective undergarments

Claudication Symptoms:

Muscle cramps in arms/hands

Arms/hands feel heavy or tired

Quality of Life/Work Capacity:

Difficulty performing routine activities of daily living (getting dressed, attending to personal hygiene, toileting

Needs assistance with these tasks

Quality of Life/Work Capacity:

Unable to perform routine pre-injury work-related responsibilities

Family life affected

Intimacy affected

Cervical Spine Intake

Patient Name

Date of Birth

MM slash DD slash YYYY

Assistive Ambulatory Device(s):

Cane

Crutches

Walker

Wheelchair

Conservative Measures Tried:

Activity modification:

Helped

Didn’t help

Conservative Measures Tried:

Weight reduction:

Helped

Didn’t help

Conservative Measures Tried:

Acupuncture:

Helped

Didn’t help

Conservative Measures Tried:

Chiropractor:

Helped

Didn’t help

Conservative Measures Tried:

Physical therapy:

Helped

Didn’t help

Conservative Measures Tried:

Neck brace:

Helped

Didn’t help

Conservative Measures Tried:

Medications:

Acetaminophen:

Helped

Didn’t help

Medications:

NSAID’s:

Helped

Didn’t help

Medications:

Medrol Dose Pack/Steroids:

Helped Neck

Helped Arms/Hands

Didn’t help

Medications:

Oxycodone/Percocet:

Helped

Didn’t help

Medications:

Hydrocodone/Vicodin:

Helped

Didn’t help

Medications:

Gabapentin/Neurontin:

Helped

Didn’t help

Medications:

Flexeril/Muscle Relaxors:

Helped

Didn’t help

Interventional Measures Tried:

Trigger point injections:

Helped Neck

Helped Arms/Hands

Didn’t help

Interventional Measures Tried:

Radio Frequency Ablation

Helped Neck

Helped Arms/Hands

Didn’t help

Radio Frequency Ablation:

Facet Joint Block:

Helped Neck

Helped Arms/Hands

Didn’t help

Radio Frequency Ablation:

Epidural steroid injection:

Helped Neck

Helped Arms/Hands

Didn’t help

Radio Frequency Ablation:

Previous Surgery:

Helped Neck

Helped Arms/Hands

Didn’t help

Previous Neck Surgery of Any Kind:

Other Case Notes:

Current Pain Management Specialist:

Shein Orthopaedics

Shein Orthopaedics combines time-honored techniques and revolutionary treatments to provide patient-centered orthopedic care that helps you get your life back.

At Shein Orthopaedics, we work closely with you to fully understand your condition and how it affects your life. Then, we draw on three generations of orthopedic experience to design a comprehensive care plan focused on you.

Locations

1250 Waters Place
Tower 1, Suite 903
Bronx, NY 10461

1919 Greentree Rd,
Cherry Hill, NJ 08003

55 Meadowlands Parkway
4th Floor
Secaucus, NJ 07094

Opening Hours

Monday -Friday: 8AM-5PM
Saturday & Sunday: Closed

Contact Us

Call Us: (866)411-0455
Fax: (866)411-1867
[email protected]

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