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155257570485PATIENT FOLLOW-UP VISIT FORMStephen P. Courtney, MD. P.A.Board Certified Fellowship Trained Orthopedic Spine Surgeon020000PATIENT FOLLOW-UP VISIT FORMStephen P. Courtney, MD. P.A.Board Certified Fellowship Trained Orthopedic Spine SurgeonPATIENT NAME: Date: / /DX test: X-RAY / MRI / CT Test Date: / / Imaging Facility:C3/4 L1/2C4/5 L2/3C5/6 L3/4C6/7 L4/5C7/T1 L5/S1Facet Arthrosis Decreased Disc SpaceBone SpursSubluxationFusedStenosisHNP I REVIEWED IMAGING & RADIOLOGY REPORT WITH THE PATIENT.HNP SPONDYLOSISRAD.HISTORY FUSIONSTRAINC3-C4M50.21CM47.812CM54.12CM43.22CS16.1XXC4-C5M50.221CTM47.813CTM54.13CTM43.23TS29.012C5-C6M50.222TM47.814LM54.16LM43.26LS39.012C6-C7M50.223TLM47.815LSM54.17LSM43.27DDDC7-T1M50.23L M47.816SI PAINSPONDYLOLISTHESISC4-C5M50.321LM51.26LSM47.817RtM53.3LM43.16C5-C6M50.322LSM51.27LtM53.3LSM43.17C6-C7M50.323STENOSISPOST-OPPOST-LAMI PAINLM51.36CM48.02LM48.06Z48.89M96.1LSM51.37CTM48.03LSM48.07OTHER DX:PATIENT OFFICE VISIT/EDUCATION:PLAN: I reviewed imaging with patient, they took MRI/CT scan- Cervical/Lumbar- R/O HNP/Stenosis pictures of images on cell phone. I reviewed anatomy Physical Therapy: ___________________________ on spine models. Injections: _________________________________ Gave patient copy of imaging report. Circle of Pain, Band of Back Pain Patterns of Pain, Workout Handout What to expect: Microdisk/Lumbar/Cervical fusion Surgery: ___________________________ Post-op: XR shows hardware in good position/stable. Staples: ____ Removed ____ # Left Intact Post-op: XR shows hardware in good position/stable/ Cervical Surgery Booklet Lumbar Surgery Booklet patient acknowledges the hardware used/we reviewed ESI Handout (if >80% improv sx x2 inj., will do RFA) the xray together, I placed the models, instrumentation Prescriptions given today: hardware in their hands & fully discussed the surgery Prednisone 9-day taper and what implants were used. Muscle relaxer Trigger Point Injection: Pain Medication ___ cc Marcaine Other: __________ ___ cc Lidocaine ___ cc Depo-Medrol RTC: ______________________________________Date: ____/____/____ Int.: ______155257595250PATIENT FOLLOW-UP VISIT FORMStephen P. Courtney, MD. P.A.Board Certified Fellowship Trained Orthopedic Spine Surgeon020000PATIENT FOLLOW-UP VISIT FORMStephen P. Courtney, MD. P.A.Board Certified Fellowship Trained Orthopedic Spine SurgeonPatient Name: Date: / /Height: Weight: DOB:Age:Preferred Pharmacy: Phone: Zip: ? I am here to follow up on: Neck visit Back Visit Post-op Neck Post-op Back Surgery: _________Post-Op: 2 weeks 6 weeks 3 months 6 months 12 monthsF/U visit: MRI F/Up CAT Scan F/Up Injection F/Up Pre-Op Other? Description of the Symptoms Please check description(s) pertaining to your chief complaint:Duration of symptoms: wk. mo. yr. Status of symptoms: Better Worse Unchanged DifferentHow much better are you? On a scale of 0-100%: Do you have weakness? Yes NoDescribe your pain: Neck Back Right Left Pain Throbbing Stiffness Popping Localized Worse when sitting Dull Intermittent Stabbing Burning Weakness Worse when standing Sharp Constant Shooting Aching Numbness/Tingling▼▼ MUST CIRCLE PAIN RATING ▼▼Where exactly do you hurt? Use these symbols to circle and mark. Please draw a line if your symptoms radiate to arms and legs.3242945107315Numbness Pins & Needles Burning Aching Stabbing ---------- oooooooo xxxxx ---------- oooooooo xxxxx 020000Numbness Pins & Needles Burning Aching Stabbing ---------- oooooooo xxxxx ---------- oooooooo xxxxx List ALL medications/dose you are taking: ▼▼DR. COURTNEY REQUIRES MARKING BODY DIAGRAM COMPLETELY BEFORE BEING SEEN ▼▼Anti-inflammatories:Muscle Relaxers:Pain Meds: Illicit Drugs: Other:? If you have done: Physical Therapy No Yes Where: Spinal Injections No Yes When: How are YOU doing overall? Where exactly do you hurt? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What do YOU WANT from today’s visit?____________________________________________________________________________________________________________________________________________________________________ Date: ____/____/____ Int.: _____ ................
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