Pledger

Orthopedic &

Spine

Center

 
  
 
 
 
 
 
  
 
 
NEW NECK 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 neck pain has been:

Acute
Suddenly
Suddenly, following an incident, not at work
Suddenly, following an incident at work
Suddenly, following no specific incident

Gradual
Gradually, over time
Gradually, following no specific incident
Gradually, following an incident at work
Gradually improving
Gradually worsening
I have had my pain for the last:
Days
Weeks
Months
Years
The pattern of my pain has been:
Increasing
 Episodic
Decreasing
Recurrent
The pattern of my pain:
Comes and goes
Increases with activity
Is present all the time
 Is related to the level of activity
Is present all the time with flare-ups
 Is unrelated to the level of activity
My neck pain can be characterized as:
Dull aching
Needles and pins
Burning sensation
Numbness
Catching
Piercing
Cramping
Sharp Stabbing
Discomfort
Shooting
Electrical
Tightness
Pain
Tingling
The severity of my pain can be described as:
Mild in severity
Moderate to severe
Mild to moderate in severity
Severe
Moderate in severity
 
My pain usually occurs:
At rest
With normal activities
All the time
On exertion
Both day and night
Only during exertion
In the daytime
When lying down
On arising in the morning
When walking
Occurs more in the early morning
More at night
Only during the day
Only at night
More toward the evening
At night
Neck pain versus arm pain is:
Arms hurt much more than the neck
Arms hurt somewhat more than the neck
Arms and neck hurt about the same
Neck hurts somewhat more than the arm
Neck hurts much more than the arm
The pain usually starts in the:
Occiput
In the neck
Midline of neck
Left side of the neck
Mid back
Right side of the neck
Right lateral neck
Neck and throat
Left lateral neck
  
The pain radiates into my:
Right shoulder
Right forearm
Left shoulder
Left forearm
Both shoulders
Both forearms
Right shoulder blade
Right thumb and index finger
Left shoulder blade
Left thumb and index finger
Both shoulder blades
Right long finger
Right upper arm
Left long finger
Left upper arm
Right ring and little finger
Both upper arms
Left ring and little finger
Arm numbness: (If the answer to this question is NO, skip the next question)
There is no arm numbness
There is arm numbness
The location of the arm numbness is:
Right shoulder
Right thumb and index finger
Left shoulder
Left thumb and index finger
Right upper arm
Right long finger
Left upper arm
Left long finger
Right forearm
Right ring and little finger
Left forearm
Left ring and little finger
Arm weakness: (If the answer to this question is NO, skip the next question)
There is no arm weakness
There is arm weakness
The location of my arm weakness is:
Right shoulder
Left forearm
Left shoulder
Right wrist weak
Right upper arm
Left wrist weak
Left upper arm
Right hand weak
Right forearm
Left hand weak
My neck pain was originally caused by:
Nothing
Boating accident
Aging
Falling
Trauma
Sports activities
Automobile accident
Exercise
Motorcycle accident
Exertion
My pain is aggravated by:
Nothing
Bending to the right
Sneezing
Bending to the left
Coughing
Rotating to the right
Twisting
Rotating to the left
Lifting
Flexion
Position of arm
Extension
My pain is relieved by:
Nothing
Holding arm above head
Bed rest
Popping of the neck
Change in position
Massage
Exercise
Oral steroids
Medication
Pain medication
Heat
Anti-inflamatory medication
Ice
Facet injections
Physical Therapy
My pain interferes with the following:
Nothing about my lifestyle
Intercourse occasionally
Personal grooming
Intercourse frequently
Driving
Sweeping
Bathing
Gardening
Work severely
Vacuuming
Work moderately
Leisure activities
Work minimally
Leisure activities not at all
Work not at all
Sleep severely
Cooking
Sleep moderately
Childcare
Sleep minimally
Intercourse never
Sleep not at all
Associated with my pain, are the following conditions:
Arthritis
Incontinence of urine
Chills
Incontinence of stool
Neck stiffness
Arm weak
Gait abnormality
Paresthesias in arms
Catching
Trauma
Bladder dysfunction
Use of corticosteroids
Dysuria
Use of anticoagulants
Fever
History of malignancy
Shoulder pain
Previous diagnostic test:
None
CT
Plain radiographs
CT/Myelogram
MRI - neck
Bone scan
MRI - right shoulder
EMG/PNCV's
MRI - left shoulder
DexaScan
I have previously been evaluated by:
None
Physiatrist
Orthopaedic surgeon
Chiropractor
Neurosurgeon
Emergency room
Neurologist
Urgent care center
Primary care physician
Pain management
Rheumatologist
Psychologist/psychiatrist
I have had the following physical therapy:
None
Ultrasound
Stretching exercises
Phonophoresis
Strengthening exercises
Iontophoresis
Active range of motion exercises
Massage
Active assisted range of motion exercises
Whirlpool
Passive range of motion exercises
Heat
Home exercises
Ice
TENS unit
Traction
I have had the following neck surgeries:
None
Posterior spinal decompression
Cervical diskectomy
Posterior spinal fixation
Cervical fusion
Posterior spinal fusion
Anterior cervical plating
Cervical total disc replacement
Posterior cervical laminaplasty
Cervical corpectomy
Posterior cervical decompression
Anterior cervical diskectomy and fusion
I use the following assistive devices:
None
Miami J collar
Cervical collar
Philadelphia collar
Because of my neck, I have the following issues:
None
Pending lawsuit
Pending Social Security disability application
Pending worker's compensation claim
Worker's compensation claim
Social Security
Pending litigation
Divorce
Previous worker's compensation claim
Child support
   

 
 
 
  
 

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

Get Driving Directions


Click to enlarge map