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

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