HEAD / NECK / SPINE QUESTIONNAIRE



HEAD / NECK / SPINE QUESTIONNAIRE

NAME: __________________________________ DATE: ___________

Have you had previous imaging studies on your head, neck, or spine? If so, what study?

μ MRI  μ CT Scan μ X-Rays  μ Other If so, where?____________________________

Have you ever had surgery on your head, neck, or spine?______ If so, what? ____________when?________

What is your approximate weight? _________ lbs

Are you, or do you think you may be pregnant?  μ No  μ Yes

Please check any of the following that pertain to your exam today…

Do you have a history of cancer? ______ If so, what type or where? ________________________________

Have you been diagnosed with MS? μ No μ Yes If so, approx. when? ______________________

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NECK, BACK, OR SPINE SYMPTOMS

 μ Neck Pain

 μ Mid back pain

 μ Low back pain

 μ Neck injury If so, when? _______________

μ Back injury If so, when? _______________

 μ Arm pain Which arm?_________

 μ Arm numbness Which arm? ________

 μ Arm weakness Which arm? ________

 μ Leg pain Which leg? _________

 μ Leg numbness Which leg? _________

 μ Le؀ࠐࠣ࠽ࡁࡂࡋࡐ࡞࡟ࡠࡥ࢐࢙࢜ࢡࢮࢯࣅࣱ࣍࣬ࣴआइ਀ਂ਒ਔਘਮਰ੄ੈ੔પબમ૪ନ������뫆ꊮ鎛鎋鎛莇荿荻荷桷荻荨荨荨荷莇dᘆ굨琟ᔜ㩨g weakness Which leg?_________

 μ Sciatica

 μ Difficulty swallowing

 μ Hoarseness

μ Neck swelling, mass or lump

If so, where? ________



μ Other spine symptoms______________________

HEAD OR BRAIN SYMPTOMS

μ Headache

 μ Head injury

 μ Facial pain

 μ Facial numbness

 μ Nausea

 μ Dizziness

 μ Fainting

 μ Seizure

 μ Fatigue

 μ Tremors

 μ Lack of coordination

μ Weakness of a body part

If so, which body part _____________

 μ Trouble walking

 μ Blurred vision

 μ Double vision

 μ Visual defect

 μ Eye swelling, enlargement, or mass

 μ Memory loss

 μ Confusion

 μ Trouble speaking

 μ Hearing loss Which ear? ______

 μ Ringing in ears Which ear?______

 μ Loss of taste or smell

 μ Sinusitis

μ Other symptoms_____________________

THANK YOU!

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