Central States Orthopedic Specialists
  6585 South Yale, Suite 200
  Tulsa, OK 74136

Patient's Name:  Middle:  Last Name: 
Occupation:  Age: 
 
How long have you had the present pain?   WEEKS   MONTHS   YEARS
How long have you had any trouble with your back, legs, or neck?   WEEKS   MONTHS   YEARS
How long have you been off work or unable to do normal housework?   WEEKS   MONTHS   YEARS
Did your pain begin (check one):   Gradually   Suddenly   From an Injury   At Work
Is your pain (check one):   Continuous   Off and On   Neither
 
My pain is (Please Check Appropriate Answer): Better Worse Unchanged
    WITH COUGH OR SNEEZE      
    SITTING DOWN AT A TABLE      
    BENDING FORWARD TO BRUSH TEETH      
    WALKING SHORT DISTANCE      
    LYING FLAT ON BACK      
    LYING FLAT ON STOMACH      
    LYING ON SIDE WITH KNEES BENT      
    WHEN I AWAKE IN THE MORNING      
    MID-MORNING      
    MIDDLE OF THE NIGHT      
My back sometimes gets "stuck" when I bend forward.   Yes   No
My back feels it is likely to give way when I bend forward.   Yes   No
My pain stops me after I walk a certain distance.   Yes   No
After walking, bending forward improves my pain.   Yes   No
How many times have you been in a hospital for back, leg, or neck problems?   
Have you had previous back surgeries?   Yes   No
Type?   
Have you had other types of surgeries?   Yes   No
Type?   
Have any treatments made your pain better?   Yes   No
What Treatments?   
Have any treatments made your pain worse?   Yes   No
What Treatments?   
What is the most aggravating thing about your pain?   

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