spine midwest, inc

Patient Disclosure: Consulting Agreements/Industry Relationships
Dear Patient:
As you prepare for your appointment, we want to provide you with some information regarding SSM Health Spine and Pain
Management Center work with industry.
SSM Health Spine and Pain Management Center has been active in research and development of new implants and
improved surgical instruments and techniques. As part of this work, we are working with several companies providing consulting
services on new products and input on research and development. In addition, the physicians at SSM Health Spine and Pain
Management Center routinely give instructional lectures on implants and teach surgical techniques to other doctors and medical
personnel. In return for this time and expertise, SSM Health Spine and Pain Management Center receives
consulting fees and royalties.
Our office uses products from some of these companies in the care of patients, but also uses similar products from other
implant manufacturers. We want to assure you that the selection of which product to use in your care, and the care of all of
our patients, is based only on what is best for the patient, not on which company makes the product.
The physicians of SSM Health Spine and Pain Management Center are members of the American Academy of Orthopaedic
Surgeons (AAOS) which holds its members to extremely high ethical standards to ensure that even the appearance of a
conflict of interest does not jeopardize the trust that patients place in our doctors.
AAOS has adopted Standards of Professionalism that require orthopaedic surgeon members to identify and disclose potential
conflicts of interest to their patients, the public, and colleagues. These Standards also clearly articulate how and under what
circumstances AAOS members may work with and be compensated by industry, as well as the penalties for failure to comply.
You can learn more about these Standards of Professionalism at the AAOS website:
http://www.aaos.org/industryrelationships.
The following are a list of companies with which SSM Health Spine and Pain Management Center is working currently or has
worked in the past. These companies are involved in the production of equipment for heathcare or spinal surgery.
•
•
•
•
•
•
•
AOI Medical
Pioneer Surgical
Alphatech
Piper Jaffray
Bacterin
Scient’X, SA
Bioset
•
•
•
•
•
•
•
SpineArt USA
Broadwater
Theken Spine
CanAccord Adams
TranS1
Eurosurgical, SA
US Spine
•
•
•
•
•
•
Exactech
Vertebron
Facet Solutions
VTI
HealthPoint
Capital
Wright Medical
•
•
Nuvasive
Technologies
Orthtofix
Some of the products made by the aforementioned companies may be used in your care. SSM Health Spine and Pain
Management Center also uses products from companies with which we do not consult.
It is important to our office that you are aware of these relationships with implant manufacturers, that our office puts the
interests of the patients first, and that we are available to answer any questions that you may have.
____________________________
Patient Signature
______________
Date
2505 Mission Drive - Suite 200 - Jefferson City, MO 65109
Phone: 573-681-3759 - Fax: 573-681-3659
Date:__________
Medical History and Review of Systems
Name:
DOB:
No
Do you have an Advanced Directive? Yes
Age:
Gender:
When was your last Tetanus?
Does your religous affiliation affect any medical treament you may receive? NO YES Explain:_________________
PAST MEDICAL / SURGICAL HISTORY:
fractures, and WHEN they occurred.
Please list all hospitilizations, operations, serious illnesses / injuries,
If you are a minor, are your immunization current?
HAVE YOU EVER HAD ANY OF THE FOLLOWING?
Cancer
Diabetes
Kidney Disease
Heart Trouble
Heart Attack
High Blood Pressure
If not, which ones?
No
Check the appropriate boxes and enter the year it occurred.
Epilepsy (seizures)
Anemia
Blood Transfusion
Venereal Disease
Thyroid Disease
Scarlet Fever
Rheumatic
Measles
Mumps
Chicken Pox
Any other diseses?
FAMILY HISTORY:
Age
Yes
Please indicate health status of your immediate family members.
Health Conditions
Deceased?
Age
Cause of Death
Father:
Mother:
Sister:
Brother:
Has any blood relative ever had any of the following? Please check the appropriate box and indiacate who.
Stroke
Cancer
Substance Abuse
Anemia
Tuberculosis
Migraine
Epilepsy
Diabetes
Hepatitis
Bleeding Tendency
Heart Trouble
Kidney Trouble
High Blood Pressure
Asthma
S
M
D
W
SOCIAL HISTORY:
Marital Status:
OCCUPATION:
EDUCATION LEVEL:
Former
Never
Year Quit
SMOKING: Current
How many years smoked?
E-Cig
Pipe
Chew
Packs per day?
What other forms of tobacco do you use? Cigar
Coffee #per day
Cola #per day
Tea # per day
CAFFEINE:
None
ALCOHOL:
Occasional / Frequency?
Daily / # drinks/day
How long have you used alcohol?
Year Stopped Drinking
RECREATIONAL DRUG USE:
OTHER:
ALLERGIES
MEDICATIONS
Please list ALL prescription & over-the-counter medications, birth control, & vitĂmins
Dosage:
Medication Name:
Page 1 of 2
Frequency:
SKIN:
Explain:
HEENT:
Please check all appropriate boxes and explain if needed
Skin Cancer
Changing Moles
Weight Change
None
None
Glasses
Hearing Loss
Glaucoma
Contacts
Migraines
Cataracts
Sore Throat
Thyroid Trouble
Nose Bleeds
Night Sweats
Excess hot/cold
Swollen Glands
Pneumonia
Seasonal Allergies
Inhaler Usage
Shortness of Breath
How many pillow do you sleep on at night?
Couging Up Blood
Asthma
Persistent Cough
Portable Oxygen
Chest Tightness
Heart Murmur
Explain:
RESPIRATORY:
None
Explain:
CARDIOVASCULAR:
None
Chest Pain
Pacemaker
Ankle Swelling
Heart Flutter
Blood Clot
Wake up with…?
Congestive Heart Failure
Heart Attack
Chest Pain
Shortness of Breath
Ulcer
Diarrhea
Black Stools
Blood in Stool
Hemmorrhoids
Gas
Colon Polyps
Vomit Blood
Laxative Use
Constipation
Explain:
GASTROINTESTINAL:
None
Avoid Certain Foods
Explain:
GU/RECTAL:
Explain:
GYNECOLOGICAL:
None
Blood in Urine
Hernia
Nightly # of urination
Prostate Exam
Difficult / Painful Urination
Daily # of urination
Last PSA
Rectal Pain
Please enter the dates for the following events
Last Menstrual Cycle
Menses Onset
Duration
Regular Cycles
Last Mammogram
Irregular Cycles Last Pap
Menopause Onset
Hormone Replacement Therapy
Abnormal Pap:
Treatment recevied for abnormal Pap?
Explain:
MUSCULOSKELETAL:
None
Gout
Herniated Disk
Redness
Edema
Cramps
Muscle Pain
Fracture
Sprain
Muscle Weakness
Carpal Tunnel
Joint Pain
Rheumatoid Arthritis
Loss of conscience
Paralysis
Strokes
Dizziness
Numbness
Tremors
Migraines
Headaches
Right Handed
Seizures
Nervousness
Left Handed
Explain:
NEUROLOGICAL:
None
Explain:
I attest that that information given on this form is accurate to the best of my knowledge.
I understand that it is my responsibility to update this office when any changes occur.
Signature:
Page 2 of 2
TM
SF-12v2
LAST NAME:____________________________
Health Survey
FIRST NAME: ___________________
(SF-12 v2 Standard, US Version 2.0)
DOB: ________________
To be completed by the PATIENT
Directions: This survey asks for your views about your health. This information will help you keep track of how you feel and how
well you are able to do your usual activities. If you need to change an answer, completely erase the incorrect mark and fill in the
correct circle. If you are unsure about how to answer a question, please give the best answer you can.
Today's Date (MM/DD/YY)
/
/
Mark only one answer for each question.
Please do not mark outside the circles or
make stray marks on the questionnaire.
Shade circles like this:
Not like this:
Excellent
Very Good
Good
Fair
Poor
01. In general, would you say your health is:
The following questions are about activities you might do during
a typical day. Does your health now limit you in these activities?
If so, how much?
Yes,
limited
a lot
Yes,
limited
a little
No, not
limited
at all
02. Moderate activities, such as moving a table, pushing a
vacuum cleaner, bowling, or playing golf
03. Climbing several flights of stairs
During the past 4 weeks, how much of the time have you had any
of the following problems with your work or other regular daily
activities as a result of your physical health?
All
of the
time
Most
of the
time
Some
of the
time
A little
of the
time
None
of the
time
All
of the
time
Most
of the
time
Some
of the
time
A little
of the
time
None
of the
time
04. Accomplished less than you would like
05. Were limited in the kind of work or other activities
During the past 4 weeks, how much of the time have you had any
of the following problems with your work or other regular daily
activities as a result of any emotional problems (such as feeling
depressed or anxious)?
06. Accomplished less than you would like
07. Did work or activities less carefully than usual
08. During the past 4 weeks, how much did pain interfere with
your normal work (including both work outside the home
and housework)?
Not at all
These questions are about how you feel and how things have been
with you during the past 4 weeks. For each question, please give
the one answer that comes closest to the way you have been feeling. All
of the
How much of the time during the past 4 weeks...
time
A little bit
Most
of the
time
Moderately
Some
of the
time
09. Have you felt calm and peaceful
10. Did you have a lot of energy
11. Have you felt downhearted and depressed
12. During the past 4 weeks, how much of the time has your
physical health or emotional problems interfered with your
social activities (like visiting friends, relatives, etc.)?
Identifi)LUVWion)LUVW1DPH Number
© 1994, 2002 by QualityMetric Inc. and Medical
Outcomes Trust. All Rights Reserved.
15
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Quite a bit
A little
of the
time
Extremely
None
of the
time
(For Internal Use Only)
LAST NAME: ____________________________
EuroQol EQ-5D
Identification
Number
FIRST NAME:___________________
To be completed by the PATIENT
Event
Directions: Answer every question by filling in the correct circle or
writing in the information. If you need to change an answer, completely
erase the incorrect mark and fill in the correct circle. If you are unsure
about how to answer a question, please give the best answer you can.
Mark only one answer for each question.
Today's Date (MM/DD/YY)
/
/
Shade circles like this:
Not like this:
DOB:________________
To help people say how good or bad a
health state is, we have drawn a scale
(rather like a thermometer) on which
the best state you can imagine is marked
100 and the worst state you can imagine
is marked by 0.
100
90
By filling in one circle in each group below, please indicate which
statement best describes your own health state today. Do not fill more
than one circle in each group.
01. Mobility
I have no problems in walking about
We would like you to indicate on this
scale how good or bad your own health
is today, in your opinion. Please do this
by drawing a line from the box below to
whichever point on the scale indicates
how good or bad your health state is.
80
I have some problems in walking about
70
I am confined to bed
02. Self-care
I have no problems with self-care
60
I have some problems washing or dressing myself
I am unable to wash or dress myself
Your own
health state
today
03. Usual activities (e.g. work, study, housework, family or
leisure activities)
50
I have no problems with performing my usual activities
I have some problems with performing my usual activities
40
I am unable to perform my usual activities
If you complete this form
via a computer,
please write the
30
corresponding number
in the gray box above.
04. Pain/discomfort
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort
20
05. Anxiety/depression
I am not anxious or depressed
I am moderately anxious or depressed
FOR PHYSICIAN OFFICE USE ONLY
I am extremely anxious or depressed
06.
10
Score
0
44858
© EuroQol
Group
295
09/23/2011 11:21:47 AM
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LAST NAME:____________________________
Modified Neck Disability Index v1.2
FIRST NAME:___________________
Reproduced from Vernon H. Mior S. The Neck Disability Index: A study of reliability and
validity. Journal of Manipulative and Physiological Therapeutics 1991; 14:409-415.
DOB:________________
To be completed by the PATIENT
Directions: This questionnaire has been designed to provide the doctor with information on how your neck pain may affect your ability to
manage in everyday life. Please select and mark only one statement from each section, which applies to you. We realize you may consider
two statements in one section. However, please mark just one answer which most closely describes your situation.
Today's Date (MM/DD/YY)
/
/
Shade circles like this:
Not like this:
Please do not mark outside of the circle or make
stray marks on the form.
04. Reading (Mark only one)
01. Pain Intensity (Mark only one)
I have no pain at the moment.
I can read as much as I want to with no pain in my neck.
The pain is very mild at the moment.
I can read as much as I want to with slight pain in my neck.
I can read as much as I want with moderate pain in my neck.
The pain is moderate at the moment.
The pain is fairly severe at the moment.
I can't read as much as I want because of moderate pain in
my neck.
The pain is very severe at the moment.
I can hardly read at all because of severe pain in my neck.
The pain is the worst imaginable at the moment.
I cannot read at all.
02. Personal Care (Washing, Dressing, etc.) (Mark only one)
05. Headaches (Mark only one)
I have no headaches at all.
I can look after myself normally without causing extra pain.
I have slight headaches which come infrequently.
I can look after myself normally but it causes extra pain.
I have moderate headaches which come infrequently.
It is painful to look after myself and I am slow and careful.
I have moderate headaches which come frequently.
I need some help but manage most of my personal care.
I have severe headaches which come frequently.
I need help every day in most aspects of self care.
I do not get dressed, I wash with difficulty and stay in bed.
I have headaches almost all the time.
06. Concentration (Mark only one)
I can concentrate fully when I want to with no difficulty.
03. Lifting (Mark only one)
I can lift heavy weights without extra pain.
I can concentrate fully when I want to with slight difficulty.
I can lift heavy weights but it gives me extra pain.
I have a fair degree of difficulty in concentrating when I
want to.
Pain prevents me from lifting heavy weights off the floor,
but I can manage if they are conveniently positioned, for
example on a table.
I have a lot of difficulty in concentrating when I want to.
I have a great deal of difficulty in concentrating when I
want to.
Pain prevents me from lifting heavy weights, but I can
manage light to medium weights if they are conveniently
positioned.
I can lift very light weights.
I cannot concentrate at all.
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I cannot lift or carry anything at all.
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© 1999 - 2010 PhDx Systems, Inc.
All Rights Reserved
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First Name:________________ Last Name:_______________________ DOB:_____________
PhDx ID:
07. Work (Mark only one)
Complete Qs 22 - 24 if you had surgery to your cervical spine
VAS Pain Scales
(neck).
I can do as much work as I want to.
I can only do my usual work, but no more.
11. On a scale from 0 to 10, mark the intensity of your neck
pain during the past week, with 0 being 'None' and 10
being 'Unbearable pain'. (Mark only one)
I can do most of my usual work, but no more.
I cannot do my usual work.
I can hardly do any work at all.
None
I can't do any work at all.
0
1
2
3
4
5
6
7
8
9
10
Unbearable
12. On a scale from 0 to 10, mark the intensity of your left
arm pain during the past week, with 0 being 'None' and 10
being 'Unbearable pain'. (Mark only one)
08. Driving (Mark only one)
I can drive my car without any neck pain.
I can drive my car as long as I want with slight pain in
my neck.
None
I can drive my car as long as I want with moderate pain
in my neck.
0
1
2
3
4
5
6
7
8
9
10
Unbearable
13. On a scale from 0 to 10, mark the intensity of your right
arm pain during the past week, with 0 being 'None' and 10
being 'Unbearable pain'. (Mark only one)
I can't drive my car as long as I want because of
moderate pain in my neck.
None
I can hardly drive at all because of severe pain in my neck.
0
1
2
3
4
5
6
7
8
9
10
Unbearable
I can't drive my car at all.
09. Sleeping (Mark only one)
I have no trouble sleeping.
My sleep is slightly disturbed (less than 1 hour sleepless).
My sleep in mildly disturbed (1-2 hours sleepless).
My sleep is moderately disturbed (2-3 hours sleepless).
My sleep is greatly disturbed (3-5 hours sleepless).
My sleep is completely disturbed (5-7 hours sleepless).
10. Recreation (Mark only one)
I am able to engage in all my recreation activities with no
pain at all.
I am able to engage in all my recreation activities with
some pain in my neck.
I am able to engage in most but not all of my usual
recreation activities because of pain in my neck.
I am able to engage in a few of my usual recreation
activities because of pain in my neck.
I can hardly do any recreation activities because of pain in
my neck.
I can't do any recreation activities at all.
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© 1999 - 2010 PhDx Systems, Inc.
All Rights Reserved
10/10/2011 03:14:05 PM
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