1

Robert W. Mauthe, M.D. 4676 Route 309

Center Valley, PA 18034

PATIENT HISTORY FORM

NAME: _________________________________ DOB: ____________ DATE: __________

Date of Onset: ____________________ Height: ___________ Weight: ________________

Referred by: __________________________ SS#: ____________________ Male/Female

PRESENT HISTORY:

1. How did the injury occur? ________________________________________________

_____________________________________________________________________

_____________________________________________________________________

2. Where is the location of the most severe pain you have? _______________________

_____________________________________________________________________

_____________________________________________________________________

3. Have you had this type of pain before? ( ) Yes ( ) No

If yes, when? __________________________________________________________

4. What is the name of your employer? _______________________________________

_____________________________________________________________________

_____________________________________________________________________

5. What is the type of business of that company? _______________________________

_____________________________________________________________________

_____________________________________________________________________

6. What was your job title when the pain began? ________________________________

_____________________________________________________________________

_____________________________________________________________________

7. What was your usual job? _______________________________________________

_____________________________________________________________________

_____________________________________________________________________

8. What were you doing when your pain began? ________________________________

_____________________________________________________________________

_____________________________________________________________________

9. Is there modified or alternative work at your job?

( ) yes ( ) No ( ) Don’t know

2

10. Where is your pain? (check all that apply):

□ Head □ Neck □ Back □ Buttock

Left: □ Shoulder □ Arm □ Hand □ Hip □ Leg □ Knee □ Foot

Right: □ Shoulder □ Arm □ Hand □ Hip □ Leg □ Knee □ Foot

□ None of These

11. Your pain is: Better Worse No Different

When you urinate or move your bowels ( ) ( ) ( )

When coughing or sneezing ( ) ( ) ( )

When you wake up in the morning ( ) ( ) ( )

In the middle of the night ( ) ( ) ( )

Mid-day ( ) ( ) ( )

Lying ( ) ( ) ( )

Sitting ( ) ( ) ( )

Driving ( ) ( ) ( )

Bending ( ) ( ) ( )

Standing ( ) ( ) ( )

Walking ( ) ( ) ( )

Change in position ( ) ( ) ( )

Cold damp weather ( ) ( ) ( )

12. What has helped this pain the most? ________________________________________

______________________________________________________________________

______________________________________________________________________

13. What has not helped or made this pain worse? ________________________________

______________________________________________________________________

______________________________________________________________________

14. Do you get pain at the tip of your tailbone? ( ) Yes ( ) No

15. Does your whole arm ever become painful? ( ) Yes ( ) No

16. Does your whole leg ever become painful? ( ) Yes ( ) No

17. Does your whole arm or leg ever go numb? ( ) Yes ( ) No

18. Do you drop things? ( ) Yes ( ) No

19. In the past year, have you had any spells with very little pain? ( ) Yes ( ) No

3

20. Have you had adverse reactions or complications as a result of your treatment?

( ) Yes; explain_______________________________________________ ( ) No

21. Estimate how long you can do the following:

Sit _______________

Stand ____________

Walk ____________ How Far __________________

22. Do you drive a car or truck? ( ) Yes; Standard or Automatic? ( ) No

For what distance or time? ________________________________________________

______________________________________________________________________

23. Circle the activities YOU CANNOT PERFORM: dress, bathe, vacuum, light

dusting/cleaning, make a bed, laundry, grocery shopping, child care.

PAST HISTORY

24. Have you ever had an x-ray, CT scan, MRI, or myelogram?

X-ray ( ) Yes ( ) No Date_____________ Where __________________________

______________________________________________________________________

CT Scan ( ) Yes ( ) No Date_____________ Where __________________________

______________________________________________________________________

MRI ( ) Yes ( ) No Date _______________ Where__________________________

______________________________________________________________________

Myelogram ( ) Yes ( ) No Date___________Where__________________________

______________________________________________________________________

25. Have you had surgery for this or any other problem? If so, list ____________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

26. What other medical problems do you have?

( ) Heart, blood pressure, or circulation problems

( ) Diabetes

( ) Arthritis

( ) Gout

( ) Cancer

( ) Other ______________________________________________________________

______________________________________________________________________

4

27. What medications are you now taking, including over-the-counter? How often?

______________________________________________________________________

______________________________________________________________________

28. Do you have a family doctor? ( ) Yes ( ) No

Name: ________________________________________________________________

Address: ______________________________________________________________

______________________________________________________________________

29. Allergies to food, medicine, or other? ( ) Yes ( ) No

List: __________________________________________________________________

______________________________________________________________________

______________________________________________________________________

30. Do you smoke? ( ) Yes ( ) No Do you chew tobacco? ( ) Yes ( ) No

31. Do you drink beer, wine, or liquor? ( ) Yes ( ) No How much? ________________

______________________________________________________________________

32. Do you drink coffee, tea, or caffeine drinks? ( ) Yes ( ) No

How much per day? _____________________________________________________

______________________________________________________________________

33. How much formal education do you have? Where and when completed?

( ) College or higher? ___________________________________________________

( ) Vocational training? __________________________________________________

( ) High school diploma or GED? __________________________________________

( ) Grade completed ?___________________________________________________

34. Do you have any family members with serious back or neck problems?

( ) Yes ( ) No

35. Do you ever lose control of your bladder or bowels? ( ) Yes ( ) No

If so, when and how frequently? ____________________________________________

______________________________________________________________________

36. What is your typical sleeping pattern? _______________________________________

______________________________________________________________________

______________________________________________________________________

37. Did you go for physical therapy? ( ) Yes ( ) No

Where? _______________________________________________________________

How did it affect you? ____________________________________________________

38. Have you had any injections? ( ) Yes ( ) No

5

Where? _______________________________________________________________

______________________________________________________________________

Did it help? ____________________________________________________________

39. Have you ever used or are you using any illegal street drugs such as marijuana, heroin,

methamphetamines, cocaine, or other? ( ) Yes ( ) No

If so, please explain: _____________________________________________________

______________________________________________________________________

6

BELOW IS A LIST OF MEDICATIONS USED TO TREAT PAIN. INDICATE IF YOU HAVE TAKEN THE DRUG BELOW BY CIRCLING

AND WHETHER IT HELPED OR WAS OF NO EFFECT BRAND NAME: GENERIC HELPED/ SIDE EFFECTS DID NOT HELP (DESCRIBE) Actiq Fentanyl______________________________________________

Ambien Zolpidem_____________________________________________

Amrix Cyclobenzaprine_______________________________________

Anaprox/Naprelan Naproxen_____________________________________________

Avinza Morphine_____________________________________________

Catapres Oral/Patch Clonidine_____________________________________________

Celebrex Celecoxib_____________________________________________

Celexa Citalopram____________________________________________

Clinoril Sulindac______________________________________________

Cymbalta Duloxetine HCL________________________________________

Darvocet Propoxyphene HCL_____________________________________

Daypro Oxaprozin____________________________________________

Dilaudid Hydromorphone________________________________________

Dolobid Diflunisal_____________________________________________

Duragesic Patch Fentanyl______________________________________________

Effexor Venlafaxine___________________________________________

Elavil Amitriptyline___________________________________________

Flector Patch Diclofenac Epolamine___________________________________

Flexeril Cyclobenzaprine_______________________________________

Fexmid Cyclobenzaprine_______________________________________

Gabitril Tiagabine_____________________________________________

Kadian Morphine_____________________________________________

Keppra Levetiracetam_________________________________________

Ketoprofen Oral/Topical N/A_________________________________________________

Klonopin Clonazepam__________________________________________

Lidoderm Patch Lidocaine 5%_________________________________________

Lioresal Baclofen_____________________________________________

Lodine Etodolac_____________________________________________

Lyrica Pregabalin____________________________________________

7

BRAND NAME: GENERIC HELPED/ SIDE EFFECTS DID NOT HELP (DESCRIBE)

Methadone Dolophine____________________________________________

Mexiletine N/A_________________________________________________

Mobic Meloxicam___________________________________________

Motrin Ibuprofen____________________________________________

Neurontin Gabapentin__________________________________________

Opana ER Oxymorphone HCI_____________________________________

OxyContin Oxycodone___________________________________________

Pamelor Nortriptyline__________________________________________

Paxil Paroxetine___________________________________________

Percocet/Percodan Oxycodone___________________________________________

Provigil Modafinil_____________________________________________

Prozac Fluoxetine____________________________________________

Relafen Nabumetone__________________________________________

Robaxin Methocarbamol________________________________________

Sinequan Doxepin______________________________________________

Skelaxin Metaxalone___________________________________________

Soma Carisoprodol__________________________________________

Steroids/oral-injection N/A_________________________________________________

Talwin Pentazocine__________________________________________

Tolectin Tolmetin_____________________________________________

Topamax Topiramate___________________________________________

Ultracet/Ultram Tramadol_____________________________________________

Valium Diazepam____________________________________________

Vicodin Hydrocodone_________________________________________

Voltaren/oral/gel Diclofenac____________________________________________

Wellbutrin Bupropion____________________________________________

Zanaflex Tizanidine____________________________________________

Zoloft Sertraline_____________________________________________

Zonegran Zonisamide___________________________________________

Zostrix Capsaicin_____________________________________________

Other:_______________________________________________________________________

8

9

There are many words that describe pain. Some of these are grouped below. Check the words that describe the pain you have right now. Use one word per group and only groups that apply.

1. Flickering 2. Jumping 3. Prickling Quivering Flashing Boring

Pulsing Shooting Drilling Throbbing Stabbing Beating Lancinating Pounding 4. Sharp 5. Pinching 6. Tugging Cutting Pressing Pulling Lacerating Gnawing Wrenching Cramping Crushing

7. Hot 8. Tingling 9. Dull Burning Itching Sore Scalding Smarting Hurting Searing Stinging Aching Heavy 10. Tender 11. Tiring 12. Sickening Taut Exhausting Suffocating Rasping Splitting 13. Fearful 14. Punishing 15. Wretched Frightful Grueling Binding Terrifying Cruel Vicious Killing 16. Annoying 17. Spreading 18. Tight

Troublesome Radiating Numb Miserable Penetrating Drawing Intense Piercing Squeezing Unbearable Tearing

19. Cool 20. Nagging Cold Nauseating Freezing Agonizing Dreadful Torturing

10

ROLAND-MORRIS

When your back hurts you may find it difficult to do some of the things you normally do. This list contains some sentences that people have used to describe themselves when they have back pain. When you read them, you may find that some stand out because they describe you today. As you read the list, think of yourself today. When you read a sentence that describes you today, put a check in the box next to it. If the sentence does not describe you, then leave the box blank and go on to the next one. Remember, only check off the box next to the sentence if you are sure that is describes you today. 1. ( ) I stay at home most of the time because of my back. 2. ( ) I change my position frequently to try and get my back comfortable. 3. ( ) I walk more slowly than usual because of my back. 4. ( ) Because of my back, I am not doing any of the jobs that I usually do around the house. 5. ( ) Because of my back, I use a handrail to get upstairs. 6. ( ) Because of my back, I lie down to rest more often. 7. ( ) Because of my back, I have to hold on to something to get out of an easy chair. 8. ( ) Because of my back, I try to get other people to do things for me. 9. ( ) I get dressed more slowly than usual because of my back. 10. ( ) I only stand up for short periods of time because of my back. 11. ( ) Because of my back, I try not to bend or kneel down. 12. ( ) I find it difficult to get out of a chair because of my back. 13. ( ) My back is painful almost all the time. 14. ( ) I find it difficult to turn over in bed because of my back. 15. ( ) My appetite is not very good because of my back pain. 16. ( ) I have trouble putting on my socks (or stockings) because of the pain in my back. 17. ( ) I only walk short distances because of my back. 18. ( ) I sleep less well because of my back. 19. ( ) Because of my back pain, I get dressed with help from someone else. 20. ( ) I sit down for most of the day because of my back. 21. ( ) I avoid heavy jobs around the house because of my back. 22. ( ) Because of my back pain, I am more irritable and bad tempered with people than usual. 23. ( ) Because of my back, I go upstairs more slowly than usual. 24. ( ) I say in bed most of the time because of my back.

11

OSWESTRY

Please check only one answer that best and most closely describes your problem. Please answer every section.

1. Pain Intensity ( ) I have no pain at the moment. ( ) The pain is very mild at the moment. ( ) The pain is moderate at the moment. ( ) The pain is fairly severe at the moment. ( ) The pain is very severe at the moment. ( ) The pain is the worst imaginable at the moment. 2. Personal Care (washing, bathing, dressing) ( ) I can look after myself normally without causing extra pain. ( ) I can look after myself normally but it causes extra pain. ( ) It is painful to look after myself but I am slow and careful. ( ) I need some help but manage most of my personal care. ( ) I need help every day in most aspects of self care. ( ) I do not get dressed, wash with difficulty, and stay in bed. 3. Lifting ( ) I can lift heavy weight without extra pain. ( ) I can lift extra weight but it causes extra pain. ( ) Pain prevents me from lifting heavy weights of the floor, but I can manage if they are conveniently positioned on a table. ( ) Pain prevents me from lifting heavy weights off the floor, but I manage light to medium weights if they are conveniently positioned. ( ) I can lift only very light weights. ( ) I cannot lift or carry anything at all. 4, Walking ( ) Pain does not prevent me from walking any distance. ( ) Pain prevents me from walking more than 1 mile (20 minutes non-stop). ( ) Pain prevents me from walking more than ½ mile (10 minutes non-stop). ( ) Pain prevents me from walking more than ¼ mile (5 minutes non-stop). ( ) I can only walk using a cane or crutches. ( ) I am in bed most of the time and have to crawl to the toilet. 5. Sitting ( ) I am able to sit in any seat for as long as I wish. ( ) I am able to sit for as long as I wish only in my favorite seat. ( ) Pain prevents me from sitting for longer than 1 hour. ( ) Pain prevents me from sitting for longer than 30 minutes. ( ) Pain prevents me from sitting for longer than 40 minutes.

12

6. Standing ( ) I am able to stand for as long as I wish without causing extra pain. ( ) I am able to stand for as long as I wish but it causes extra pain. ( ) Pain prevents me from standing for more than 1 hour. ( ) Pain prevents me from standing for more than 30 minutes. ( ) Pain prevents me from standing for more than 10 minutes. ( ) Pain prevents me from standing. 7. Sleeping

( ) My sleep is never disturbed by pain. ( ) My sleep is occasionally disturbed by pain. ( ) Because of pain, I get less than 6 hours of sleep. ( ) Because of pain, I get less than 4 hours of sleep. ( ) Because of pain, I get less than 2 hours of sleep. ( ) Pain prevents me from sleeping at all.

8. Sex Life ( ) I am not sexually active. ( ) My sex life is normal and causes no extra pain. ( ) My sex life is normal but causes some extra pain. ( ) My sex life is nearly normal but is very painful. ( ) My sex life is severely restricted by pain. ( ) My sex life is nearly absent because of pain. ( ) Pain prevents any sex life at all. 9. Social Life ( ) My social life is normal and causes me no extra pain. ( ) My social life is normal but increases the degree of pain. ( ) Pain has no significant effect on my social life apart from restricting my more energetic interests (dancing, exercise, certain sports). ( ) Pain has restricted my social life and I do not go out often. ( ) Pain has restricted my social life to my home. ( ) I have no social life. 10. Traveling. ( ) I can travel anywhere without extra pain. ( ) I can travel anywhere but it gives me extra pain. ( ) Pain is bad but I manage journeys over 2 hours. ( ) Pain restricts me to journeys of less than 1 hour. ( ) Pain restricts me to short journeys under 30 minutes. ( ) Pain restricts me from traveling except to get treatment.

13

Describe the physical requirements of the job you were doing when you were injured. Request additional forms if you are doing a different job now.

Job Description – If This Applies To You

DATE: ______________________

NAME ____________________________ HOURS THAT JOB REQUIRES PER WEEK ____

EMPLOYER ______________________________________ FULL TIME _________________

ADDRESS _______________________________________ PART TIME ________________

JOB TITLE _______________________________________ PRN ______________________

1. In an 8 hour work day I must (circle full capacity for each activity) INTERMITTENT OR CONSTANT a. Sit ( ) 1 2 3 4 5 6 7 8 hours _____________ ___________

b. Stand ( ) 1 2 3 4 5 6 7 8 hours _____________ ___________ c. Walk ( ) 1 2 3 4 5 6 7 8 hours _____________ ___________ d. Drive ( ) 1 2 3 4 5 6 7 8 hours _____________ ___________ NOTE: In terms of an 8 hour day, “occasionally” equals 1-33, “frequently” 34-66, “continuously 67-100% 2. My job requires: NOT AT ALL OCCASIONALLY FREQUENTLY CONTINUOUSLY Squatting __________ ______________ ____________ ______________ Bending __________ ______________ ____________ ______________ Kneeling __________ ______________ ____________ ______________ Reaching __________ ______________ ____________ ______________ Twisting __________ ______________ ____________ ______________ Crawling __________ ______________ ____________ ______________ Ladder Climbing _________ ______________ ____________ ______________ Stair Climbing __________ ______________ ____________ ______________ Other Climbing (type) __________ ______________ ____________ ______________ Walking on rough __________ ______________ ____________ ______________ Exposure to changes of temperature or humidity __________ ______________ ____________ ______________

Exposure to dust, fumes, or gases __________ ______________ ____________ ______________

Being near moving Machinery __________ ______________ ____________ _______________ Working from heights __________ ______________ ____________ ______________

14

3. My job requires that I lift: NEVER OCCASIONALLY FREQUENTLY CONTINUOUSLY a. up to 10 lbs. ______ ______________ ____________ ______________ b. 11-24 lbs. ______ ______________ ____________ ______________ c. 25-34 lbs. ______ ______________ ____________ ______________ d. 35-50 lbs. ______ ______________ ____________ ______________ e. 51-74 lbs. ______ ______________ ____________ ______________ f. 75-100 lbs. ______ ______________ ____________ ______________ g. above 100 lbs. (state weight) ______ ______________ ____________ ______________ 4. My job requires that I carry: NEVER OCCASIONALLY FREQUENTLY CONTINUOUSLY a. up to 10 lbs. ______ ______________ ____________ ______________ b. 11-24 lbs. ______ ______________ ____________ ______________ c. 25-34 lbs. ______ ______________ ____________ ______________ d. 35-50 lbs. ______ ______________ ____________ ______________ e. 51-74 lbs. ______ ______________ ____________ ______________ f. 75-100 lbs. ______ ______________ ____________ ______________ g. above 100 lbs. (state weight) ______ ______________ ____________ ______________ 5. My job requires that I push: NEVER OCCASIONALLY FREQUENTLY CONTINUOUSLY a. up to 10 lbs. ______ ______________ ____________ ______________ b. 11-24 lbs. ______ ______________ ____________ ______________ c. 25-34 lbs. ______ ______________ ____________ ______________ d. 35-50 lbs. ______ ______________ ____________ ______________ e. 51-74 lbs. ______ ______________ ____________ ______________ f. 75-100 lbs. ______ ______________ ____________ ______________ g. above 100 lbs. (state weight) ______ ______________ ____________ ______________ 6. My job requires that I pull: NEVER OCCASIONALLY FREQUENTLY CONTINUOUSLY a. up to 10 lbs. ______ ______________ ____________ _______________ b. 11-24 lbs. ______ ______________ ____________ _______________ c. 25-34 lbs. ______ ______________ ____________ _______________ d. 35-50 lbs. ______ ______________ ____________ _______________ e. 51-74 lbs. ______ ______________ ____________ _______________ f. 76-100 lbs. ______ ______________ ____________ _______________ g. over 100 lbs. (state weight) ______ ______________ ____________ _______________

15

7. Tools used and weight: 01. _________________________ - ________ 11. ______________________ - _______

02. _________________________ - ________ 12. ______________________ - _______ 03. _________________________ - ________ 13. ______________________ - _______ 04. _________________________ - ________ 14. ______________________ - _______ 05. _________________________ - ________ 15. ______________________ - _______ 06. _________________________ - ________ 16. ______________________ - _______ 07. _________________________ - ________ 17. ______________________ - _______ 08. _________________________ - ________ 18. ______________________ - _______ 09. _________________________ - ________ 19. ______________________ - _______ 10. _________________________ - ________ 20. ______________________ - _______

8. My job requires use of my hands for: RIGHT LEFT BOTH

Power Grip ______ _____ _____ Speed Work ______ _____ _____ Precision ______ _____ _____ Piece Work ______ _____ _____

9. My job requires use of my feet for repetitive movements: YES NO Right ____ ____ Left ____ ____ Both ____ ____

10. Other aspects and demands of my job not listed in this description (please list):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 11. Is the above JOB AVAILABLE (WILL EMPLOYER TAKE YOU BACK)? YES ___ NO ____ 12. Is LIGHT DUTY or MEDICAL RESTRICTED DUTY available to you at your job? YES ____ NO ____

16