Patient Clinical History & Client / Patient Agreement & Consent
As part of the radiology reporting process, complete the following questions.
Best wishes,
Spine and Brain Advocate
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First Name
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Last Name
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Full address including Country of Residence
Address
Other
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Your Date of Birth in the following format Month / Day / Year
Date of Birth
Other
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What is your top area of pain/discomfort?
Head
Neck
Arms
Hands
Chest
Back
Stomach
Buttocks
Tailbone
Legs
Feet
Shoulders
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Select all conservative treatments that you have tried to-date.
Physical Therapy
Occupational Therapy
Massage Therapy and/or Tens Unit
Aqua Therapy
Nerve blocks and epidural injections
Baclofen pump
Cervical Collar to function or relieve symptoms
Narcotic Pain Medications such as Oxy, Morphine Sulfate, Fentanyl etc.
Supplements such as tumeric, omega 3 etc.
Corticosteroids
NSAIDS such as aspirin, iuprofen etc.
Other pain medications such as creams, patches etc
Lying down (out of upright postion)
Upper Cervical Chiropractor
Other
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Karnosky Scale. Select one that best describes your current situation.
100% Normal. No complaints or evidence of disease.
90% Able to carry on normal activities; minor signs or symptoms of disease.
80% Normal activities but with effort; some signs of symptoms or disease.
70% Cares for self, but is unable to carry on normal activities or to do active work.
60% Requires occasional assistance but is able to care for most needs.
50% Requires considerable assistance but frequent medical care.
40% Disabled, requires special care and assistance.
30% Severely disabled, hospitalization is indicated but death is not imminent.
20% Hospitalization necessary, very sick, active support treatment necessary.
10% Fatal processes progressing rapidly.
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Do you have Ehlers Danlos Syndrome or a connective tissue disorder diagnosis?
Yes
No
Don't know / Have not investigated or had ruled out
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Do you have Chiari Malformation diagnosis?
Yes
No
Don't know / Have not investigated or had ruled out
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Have you ever been diagnosed with Rheumatoid Arthritis?
Yes
No
Don't know / Have not investigated or had ruled out
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Have you been diagnosed with a Chronic Active Viral Infection (e.g. EBV)?
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Is there anything that occured just prior to illness onset? Select one that best describes your situation.
I had a motor vehicle accident (MVA).
I had a sports / recreational accident.
I experienced a trauma / physical accident.
I had a virus such as tonsillitis, H1N1, Covid19, Epstein-Barr Virus etc.
I had a tick bite / lyme disease.
I had a bacterial infection such as strep throat.
Tumor diagnosis
Stroke
Pregnancy
I don't know.
Other
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What symptoms do you have on a regular or a weekly basis? Select all that apply.
I experience symptoms when upright that are somewhat relieved by laying down.
I experience symptoms when upright that are completely relieved by laying down.
Neck pain
Pain in the back of my head
Pain in my eyes
Muscle pain while at rest
Leg pain while walking
Lower back pain
Tailbone pain to touch
Tailbone pain when walking
Sensitive to noise
Sensitive to light
Dizziness/lightheadedness
Vertigo / Room Spinning around
Loss of hearing
Shaking episodes / dystonia
Seizures
Tremors
Headache
Loss of consciousness
Memory Loss or decline in memory, concentration or other thinking skills
Blurred or double vision; or temporary loss of vision
Visual flashes
Eye Floaters
Sensitivity to smell
Facial numbness
Tingling or numbness in hands and/or feet
Nausea or vomiting
Choking or difficulty swallowing
Fatigue not resolved by rest
Joint pain
Swollen lymph notes
Thyroid Disorder
Increased symptoms due to automobile rides
Feeling heart beats
Shortness of breath
Fingers change color with temperature
Sleep disturbances
Elevated body temperature of over 101.5 degrees
Abnormally dilated pupils or eye movement disorder
Abdominal pain
Constipation
Diarrhea
Loss of Bowel Control
Increased frequency of urination
Loss of bladder control
Unable to empty bladder
Bedwetting
Occipital Neuralgia (pain in upper neck, back of head, behind ears, usually on one side of the head)
Muscle weakness in arms/hand/legs
Unsteady gait/walking abnormality
Face Pain
Facial Spasms / Twitches
Feeling of something stuck in throat
Torticollis
Sagging eyelid
Positional Vertigo
Tinnitis
Ear, throat or tongue pain
Tongue atrophy or weakness
Pain and stiffness in the neck, bak or lower back
Burning pain that spreads into the arms, buttocks or down into the legs
Numbness, cramping or weakness in the arms, hands or legs
Periods of confusion or conscious awareness
Loss of sensation/feeling
Loss of ability to know how joints are positioned
Difficulty swallowing or saying words due to loss of muscle control
Sleepiness or lethargy
Poor appetite
Respiratory Arrest/ineffective breathing or at some point may stop breathing
Other
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Are your symptoms pronounced on a particular side?
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List all your current diagnoses from birth to today.
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What type of study(s) have you submitted for Reporting? e.g. MRI Cervical Spine, CT Brain
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Is the study for 1st or 2nd opinion?
1st Opinion & small additional fee has been paid
2nd Opinion
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Is this a comparative study? i.e. A comparative radiology study involves analyzing and interpreting imaging studies by directly comparing them with previous or concurrent imaging studies of the same patient.
Yes & additional fee has been paid
No
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Is this a post-operative study? i.e. At any time, surgery has been performed in the area of the study.
Yes
No
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Do you agree that in no way does submitting your imaging establish any kind of physician-patient relationship; that the suggestions & opinions provided in the report are based solely on the imaging provided, with limited clinical information / examination?
Yes
No
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Do you agree that your imaging, imaging results, and recommendations may be utilized for research, and may be "rolled up into statistics" for lobbying or research purposes? (Please note, your privacy and confidentiality is highly important to us, and that your personal information will not be released).
Yes
No
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Do you agree Spine and Brain Advocate has only been hired to act as your Contracted Patient Representative and cannot provide opinions or advice?
Yes
No
Thank you for completing your patient history and agreements.