Page 1 of 3 - My Doctor Online
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KAISER PERMANENTE?
Department of Physical Medicine and Rehabilitation
2120 Professional Drive, Suite 135 & 225, Roseville, CA 95661 2025 Morse Avenue, Station 2C, Sacramento, CA 95825
916-771-6611 916-973-7481
Welcome Welcome to the Department of Physical Medicine and Rehabilitation. You have been referred to our department so that we can help create a treatment plan for your spine condition. We will work closely with your referring doctor to provide advice for the management of your condition.
Our entire staff is dedicated to providing the highest quality specialty care. Our specialists are experts in nonsurgical spine care, electrodiagnostic studies, and interventional spine procedures.
Before your visit Before your visit, please complete the New Patient Questionnaire. This questionnaire provides valuable information to help in your care. It is important that you complete the questions ahead of time, so that you have more time to work with our staff during your appointment.
You should also write down the questions or concerns you would like to talk to our staff about during your visit.
Finally, if you have been treated at a non-Kaiser Permanente facility for your spine condition, please get a copy of your medical record from the other provider. If you have had pictures taken outside of Kaiser Permanente, such as X-ray or MRI, please request both the report and hard copy of the pictures.
For your first visit When you come to your appointment, please remember to bring: Your completed New Patient Questionnaire Your current list of medications Your list of questions for the physician Your outside records, films, or CDs
What you should expect at your visit Our physicians will complete a detailed history and physician examination related to your spine condition. We will review your medical records, the information you provided, and current pictures such as X-rays and MRIs.
Often, a diagnosis is identified from your history and physical exam. However, if addition testing is needed to determine your diagnosis, this will be discussed with you.
Once a diagnosis is made, our physician will make treatment recommendations to you and your primary care physician. Based on what is best for you, our physicians may refer you to a physical therapist for exercise therapy, perform therapeutic spinal procedures, or refer you to a spine surgeon if needed. They may also recommend specific medications to help in your treatment. These may include medications to help with discomfort, trouble sleeping, nerve sensitivity, and inflammation.
Medications Your primary care physician will continue to prescribe any medications you have been taking.
Your role Rehabilitation of the spine requires your active participation. We look forward to working with you to improve and effectively manage your condition. Our goal is to give you the tools and skills needed to successfully maintain improvement over time.
Page 1 of 3
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KAISER PERMANENTE?
Department of Physical Medicine and Rehabilitation
2120 Professional Drive, Suite 135 & 225, Roseville, CA 95661 2025 Morse Avenue, Station 2C, Sacramento, CA 95825
916-771-6611 916-973-7481
Name: ______________________________ Medical Record Number: _________________________ Date: ________
Main problem: ____________________________________________________________________________________
When did the main problem start? _____________________________________________________________________
What caused your main problem? _____________________________________________________________________
?xx? Please place
on the diagram below where you are experiencing pain.
?oo? Please place
on the diagram below where you are experiencing numbness/tingling
FRONT
BACK
L-
Describe Your Pain:
_____ Throbbing _____ Shooting _____ Stabbing _____ Sharp _____ Cramping _____ Burning _____ Aching _____ Tiring
_____ Gnawing _____ Heavy _____ Tender _____ Splitting _____ Fearful _____ Punishing _____ Sickening _____ Cruel
What positions or activities make your main problem worse?
__________________________________ __________________________________ __________________________________ __________________________________
Right
Left
What positions or activities make your main problem better?
__________________________________ __________________________________ __________________________________ __________________________________
Left
Right
Circle the numbers that rate the lowest and highest amount of pain that you have experienced during the past week:
0
1
2
3
4
5
6
7
8
9
10
List the medications (including over-the-counter and supplements) that are not prescribed by a Kaiser Permanente doctor:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Do you smoke cigarettes?
Yes
No
How many alcoholic drinks do you have in 1 week? ____________ Page 2 of 3
Do you have any of the following? Fevers, chills, or night sweats Recent unintended weight loss Incontinence (loss of bladder or bowel control) Groin (genital region) numbness
Yes Yes Yes Yes
No No No No
Is today's problem related to an on-the-job injury? Have you filed a claim for today's problem with your employer? Is today's problem related to a personal injury case or motor vehicle accident? Do you have or anticipate litigation (lawsuit) regarding today's problem?
Yes Yes Yes Yes
No No No No
Unsure
Unsure
Unsure
What have you tried for your symptoms? Check all that apply and circle those that helped.
Physical therapy
Back Class
Acupuncture
Braces
Chiropractic
Traction
Yoga
Pilates
Chronic Pain Program Spine injections Inversion Table
"Managing Your Back Pain" video
Spine surgery (list dates) ______________________________________
Other _____________________________________________________
How many total minutes in one week do you exercise? _____________________________________________________
What do you do for exercise?
Walking program
Jogging
Bicycling
Exercise classes
Exercise machines Swimming
Other (please list) ___________________________________________
Please check any psychiatric or psychological problems that you have experienced:
Depression
Anxiety
Bipolar
ADD/ADHD
PTSD
OCD
Emotional, physical, or sexual abuse
Other _____________________________________________________
What is your marital status?
Single/never married
Divorced/separated
Widowed
Married/living with spouse Living with significant other
What type of work do/did you do? What is your current employment status?
____________________________________________________________
Working full-time
On sick leave Retired
Working part-time
Unemployed
On modified work Disabled
Over the last two weeks, how often have you been bothered by any of the following problems? (Circle only one number per line)
1. Little interest or pleasure in doing things 2. Feeling down depressed or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself ? or that you are a failure or have let yourself or
your family down 7. Trouble concentrating on things, such as reading the newspaper or
watching television 8. Moving or speaking so slowly that other people could have noticed. Or the
opposite ? being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead, or of hurting yourself in some way
Not at all
0 0 0 0 0 0
Several days
1 1 1 1 1 1
More than half the days
2 2 2 2 2 2
Nearly everyday
3 3 3 3 3 3
0
1
2
3
0
1
2
3
0
1
2
3
10. Feeling nervous, anxious or on edge 11. Not being able to stop or control worrying 12. Feeling unproductive at work or other daily activities 13. Having trouble focusing on achieving your goals
0
1
2
3
0
1
2
3
0
1
2
3
I0 I 1 I 2
3
Page 3 of 3
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