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Patient Clinical History
First Name
Last Name
Full address including Country
Address
Other
What imaging study(s) are you submitting for a 2nd Radiologist opinion?
Imaging study(s) for 2nd Radiology Opinion
Other
Your Date of Birth in the following format Month/Day/Year
Date of Birth
Other
Do you agree that in no way does submitting your imaging establish any kind of physician-patient relationship; the recommendations & opinions provided are based solely on imaging with limited clinical information nor examination?
Agreement
I agree that I am of legal age, come voluntarily and of my own free will to request a second opinion, I am legally able to make my own medical decisions. No one has been given power of attorney over my legal right to self-determination due to a psychiatric disorder, and this is a non-urgent radiology consultation..
Yes - I agree
No - I do not agree
Do you agree that the imaging and imaging results and recommendations may be utilized for research and "rolled up into statistics" for lobbying or research purposes? Do you agree Spine and Brain Advocate is only acting as a contracted Patient Rep.?
Yes
What is your top area of pain/discomfort?
Head
Neck
Arms
Hands
Chest
Back
Stomach
Buttocks
Tailbone
Legs
Feet
Shoulders
Select all conservative treatments that you have tried to-date.
Physical Therapy
Occupational Therapy
Massage Therapy and/or Tens Unit
Aqua Therapy
Acupuncture and/or dry needling
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)
Certified Chiropractic BioPhysics for spinal curve rehabilitation
Other
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.
Do you have Ehlers Danlos Syndrome or a connective tissue disorder diagnosis?
Yes
No
Do you have Chiari Malformation diagnosis?
Yes
No
Have you ever been diagnosed with Rheumatoid Arthritis? or Chronic Active Viral Infection (e.g. EBV)?
Yes
No
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.
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
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 joins 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
Are your symptoms pronounced on a particular side? Any other important infomation you would like to add? or what specifically would you like the Radiologist to report on?
List all your current diagnoses from birth to today.
Do you have any existing images and reports including blood tests and others? If yes, please list which images and reports you will be sending so we can ensure we receive all of them to send to the Radiology Clinic.
Thank you for completing the Patient History Form
This Form has been submitted to Spine and Brain Advocate Inc.
Please ensure your payment has been completed on the website spineandbrain.com and the applicable radiology images have been submitted to spinebrainadvocate@gmail.com to avoid any delays. Your 2nd Radiology Opinion Report will be send to you in approximately 1 week.
Thank you!