Pledger

Orthopedic &

Spine

Center

 
  
 
 
 
 
 
  
 
 
NEW BACK PAIN INTERVIEW FORM


Answer the questions below and click the submit button to automatically submit your information to Dr. Pledger's office for review and readiness prior to your scheduled appointment.

Patient Name:
Date of Appointment:
Family Physician Name:
The onset of my back pain has been:
Acute
Gradually over time
Suddenly
Gradual following no specific incident
Suddenly, following an incident not at work
Gradual following an incident at work
Suddenly, following an incident at work
Gradual following an incident not at work
Suddenly, following no specific incident
Gradually improving
Gradual
Gradually worsening
The duration of my pain has been:
Minutes:
Hours:
Days:
Weeks:
Months:
Years:
The pattern of my pain has been:
Increasing
Recurrent
Decreasing
Episodic
The pattern of my pain:
Comes and goes
Is related to the level of activity
Is present all the time
Is unrelated to activity
Is present all the time with flare-ups
Is unrelated to the level of activity
Increases with activity
 
My back pain can be characterized as an:
Ache
Needles and pins
Burning sensation
Numbness
Catching
Piercing pain
Cramping
Sharp, stabbing pain
Discomfort
Shooting pain
Dull ache
Tightness
Electrical
Tingling
Pain
  
The severity of my pain can be described as:
Mild in severity
Moderate to severe
Mild to moderate
Severe
Moderate in severity
 
My pain usually occurs:
More in the early morning
Only during exertion
More toward the evening
Both day and night
At night
When climbing stairs
At rest
When walking
How would you describe your back versus leg pain:
Back hurts much more than the legs
Back hurts somewhat more than the legs
Legs and back hurt about the same
Legs hurt somewhat more than the back
Legs hurt much more than the back
My pain starts in the:
Upper back
Both lower extremities
Middle back
Right thigh
Lower back
Left thigh
Right buttock
Right calf
Left buttock
Left calf
Both buttocks
Right foot
Right lower extremity
Left foot
Left lower extremity
 
My pain radiates to:
No radiation
Outside of right calf
Lower abdomen
Outside of left calf
Right groin
Outside of both calves
Left groin
Inside of right calf
Right testicle
Inside of left calf
Left testicle
Inside of both calves
Right buttock
Right shin
Left buttock
Left shin
Both buttocks
Both shins
Right hip
Outside of right foot
Left hip
Outside of left foot
Both hips
Outside of both feet
Front of right thigh
Top of right foot
Front of left thigh
Top of left foot
Front of both thighs
Top of both feet
Back of right thigh
Right big toe
Back of left thigh
Left big toe
Back of both thighs
Both big toes
Outside of right thigh
Right heel
Outside of left thigh
Left heel
Outside of both thighs
Both heels
Back of right calf
Bottom of right foot
Back of left calf
Bottom of left foot
Back of both calves
Bottom of both feet
My back pain was caused by:
Nothing
Falling
Exertion
Automobile accident
Lifting
Trauma
Twisting
  
My back pain is aggravated by:
Nothing
Cooking
Exertion
Vacuuming
Lying flat
Laundry
Sitting
Yard work
Sneezing
Getting in or out of chair
Coughing
Getting up out of bed in the morning
Straining on bowel movements
Going up and down stairs
Bending
Putting on socks or shoes
Twisting
Carrying groceries
Lifting
My job
Standing
Reaching overhead
Walking
Sexual intercourse
Driving
My back pain is relieved by:
Nothing
Oral steroids
Rest
Local injections
Cold compress
TENS unit
Lying down
Electric stimulation
Bed rest
Brace
Exercise
Cane
Exercise by a therapist
Crutches
Heat
Walker
Sitting
Traction
Standing
Ultrasound
Bending forward
Manipulation by a chiropractor
Physical therapy
Massage therapy
Pain medication
Epidural steroids
Anti-inflammatory medication
Home exercise program
Muscle relaxants
Transforaminal nerve blocks
Leg numbness
There is no leg numbness (if selected, skip the next question)
There is leg numbness
The location of the leg numbness:
Front of right thigh
Right shin
Front of left thigh
Left shin
Front of both thighs
Both shins
Outside of right thigh
Outside of right foot
Outside of left thigh
Outside of left foot
Outside of both thighs
Outside of both feet
Back of right thigh
Top of right foot
Back of left thigh
Top of left foot
Back of both thighs
Top of both feet
Outside of right calf
Bottom of right foot
Outside of left calf
Bottom of left foot
Outside of both calves
Bottom of both feet
Back of right calf
Right heel
Back of left calf
Left heel
Back of both calves
Both heels
Associated with my back, leg weakness is present:
Neither leg (if selected skip the next question)
Right leg
 
Left leg
 
Both legs
 
My leg weakness causes:
My legs to buckle
 
Me to fall
 
The following symptoms occur with my back pain:
Blurred vision
Parasthesias
Chest pain
Poor exercise tolerance
Cyanosis (bluish skin)
Numbness & tingling in fingers
Dizziness
Numbness & tingling in toes
Diaphoresis (sweating)
Visual disturbances
Dyspnea (difficulty breathing)
Foot/leg ulcers
Digital clubbing
Calf swelling
Fatigue
Cool extremity
Focal neurologic deficits
Cough
Muscle weakness
Fever
Pallor of extremity
Chills
Previous diagnostic tests:
None
CT Scan
Plain radiographs
CT/Myelogram
MRI - Lumbar spine
Bonescan
MRI - Thoracic spine
EMG/PNCV's
MRI - Pelvis
Discogram
MRI - Hip
 
I have previously been evaluated by:
None
Rheumatologist
Orthopaedic surgeon
Physiatrist
Neurosurgeon
Chiropractor
Neurologist
Emergency room
Urgent care center
Pain management
Primary care physician
Psychologist/psychiatrist
I have had the following physical therapy:
None
Phonophoresis
Stretching exercises
Iontophoresis
Strengthening exercises
Massage therapy
Active assisted range of motion exercises
Whirlpool
Active range of motion exercises
Heat
Home exercise program
Ice
TENS unit
Traction
Ultrasound
I have had the following spine surgeries:
None
Laminectomy & diskectomy
Posterior lumbar interbody fusion
Anterior lumbar interbody fusion
Posterior spinal fixation
Anterior spinal fixation
Posterolateral fusion without hardware
Cervical diskectomy
Posterolateral fusion with hardware
Cervical fusion
Posterolateral fusion
Scoliosis surgery
I use the following assistive devices:
None
Cane
Brace
Crutch
Full-time bracing
Walker
Corset
Wheelchair
My pain interferes with the following:
Nothing about the patient's lifestyle
Sweeping
Personal grooming
Gardening
Driving
Yard work
Walking
Vacuuming
Bathing
Leisure activities not at all
Work not at all
Leisure activities
Work minimally
Sleep not at all
Work moderately
Sleep minimally
Work severely
Sleep moderately
Cooking
Sleep severely
Childcare
Sports activities - not at all
Intercourse never
Sports activities minimally
Intercourse occasionally
Sports activities moderately
Intercourse frequently
Sports activities severely
Because of my back, I have the following issues:
None
Pending litigation
Pending social security disability application
Pending workers compensation
Previous workers compensation claim
Workers compensation claim
Social security
Divorce
Child support
I have the following medical conditions:
Acid reflux
Peripheral vascular disease
Anemia
Phlebitis
Angina
Stroke
Asthma
Long history of tobacco use
Cardiovascular disease
Coronary artery disease
Diabetes
Malignancy
Elevated cholesterol
Drug dependency
Elevated triglycerides
Drug addiction
Hypertension
Fibromyalgia
Lung disease
Neuropathy

 
 
 
  
 

STEPHEN R. PLEDGER, M.D.
1044 Summit Drive
Middletown, OH 45042
Phone: 513-420-3773
Fax: 513-420-3795

Office Hours:
Monday-Friday, 8 am-5 pm

Email:
stephen@pledgerorthospine.com
nurses@pledgerorthospine.com

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