Fill - Free fillable Dr. John C. Herzog Dr. Armin Afsar-Keshmiri Dr. PDF form

MEDICAL INFORMATION FORM

Dr. John C. Herzog

Dr. Armin Afsar-Keshmiri

Dr. Hetal T. Amin, Dr. Radka Dooley

Rick A. Varone, PA, Christopher Stephens, PA,

Christopher Evans, PA Sheilah Scofield, NP

Saratoga Office Glens Falls Office Plattsburgh Office

31 Myrtle Street 7 Murray Street 16 DeGrandpre Way Ste 100

T:518-587-7746 T: 518-587-7746 T: 518-587-7746

INITIAL PATIENT VISIT:

Name: _________________________________________________ DOB: ________________________

Address: ________________________________________________________________

_____________________

Age: ____ Sex: ____ Weight: _______ Height: ______

Phone: Home: __________________Work: ________________________ Mobile: ________________________

Social Security Number:__________________________

Email address___________________________________

Local Pharmacy name___________________________Address_________________________________________

Mail Order Pharmacy__________________________________________________________________________

Employer_____________________________Occupation_____________________________________________

Who referred you to Saratoga Spine?

Referring Physician Name__________

__________________ Referring Physician Telephone #_________________

Referring Physician Address City State Zip Code

Who is your Primary Care Physici

an? ______________________________________________________________

Please describe your main problem/complaint:________________________________________________________

CURRENT MEDICAL CONDITION:

Do you have: ___ Only Back Pain ____Back And Leg Pain ____ Only Leg Pain

___ Only Neck Pain ____Only Shoulder/Arm Pain

___ Neck, Shoulder and Arm Pain ___ Other ___________________________

Which is worse: ___Back Pain ___Leg Pain ___ Neck Pain ____ Shoulder/Arm Pain

I have had back/neck pain: ____Less t

han 1 month ___1-3 Months ____ 3-6 Months ___ 6 Months- 1 Year

____1-3 Years ___3-5 Years ____ Greater than 5 Years

My pain came on: ____Gradually, ove

r time ____Quickly

SARATOGA SPINE

NEW PATIENT PACKET

MEDICAL INFORMATION FORM

Patient name _____________________________________________

My pain was brought on by: ____No specific incident ____Fol

lowing an accident or incident at work

____ Following an accident or incident NOT at work _____Motor vehicle accident?

________ Date of accident/injury

Describe the accident/incident: _________________________________________

_______________________________________________________________________________

______

Do you have: ____Numbness: Where____________________

____Tingling: Where____________________

____Weakness: Where____________________

What time of the day is your pain worse ____Morning ___Late in the day ___The

middle of the night

My Pain pattern is: ___A single attack of pain ___A

ttacks of pain with pain free intervals

___Continuous Pain ___Continuous pain with attacks of severe pain

I experience pain: ___The entire day ___A fair amo

unt of the day (2-7 hours)

___Most of the day (16-20 Hours) ___A small amount of the day (1 hour or less)

_A good part of the day (8-15 Hours) ___Less than once a day

How long does the pain attack last: ____Seconds ___Minutes ___Hours ___Constant

For how long can you walk: ___ <15 minutes ____15-30 Minutes ___ 30-60 Minutes ___NO Restrictions

How long can you stand: ___< 15 minutes ___15-30 Minutes ___30-60 Minutes ___ NO Restrictions

Do you need assistive device (walker/crutches etc.)_________ How long using assistive device?

Do you need help getting dressed Personal hygiene? Y/N Are you able to self transport? Y/N

What position/activity make

the pain worse or better?

Standing Sitting Walking Stairs Lying Down Bending Lifting Coughing Bowel Mov’t General Activity

Better: _____ ______ _____ _____ _____ _____ _____ _____ _____ _____

Worse: _____ ______ _____ _____ _____ _____ _____ _____ _____ _____

Pain Rating Scale: How would you rate your pain today: (check One Number)

0__

None

6__ 7__ 8__ 9__ 10__ 3__ 4__ 5__

_____________________________________________________________________________________________

Saratoga Spine

1__

2__

Moderate Moderate

Severe

Worst Possible Pain

Name, Date, and Location of office you have sought help for your pain: (Fill out all that apply)

Family Doctor:____________________________________________________________________

_____

Orthopedist:___________________________________________________________________________

Spine Surgeon:_________________________________________________________________________

Physical Therapist:______________________________________________________________________

Chiropractor:___________________________________________________________________________

Pain Management:_______________________________________________________________________

Physiatrist:_____________________________________________________________________________

Neurologist:____________________________________________________________________________

Psychiatrist/Psychologist:_________________________________________________________________

Have any of th

e above treatments decreased your pain: ___ NO ___ YES, describe below

_____________________________________________________________________________________

Which medications do you take for your pain:________________________________________________

My pain now seems to be: ___ Getting better ___ Staying the same ___ Getting worse

Have you noticed any change in your bowel or bladder habits? ___ NO ___ YES, describe:

_____________________________________________________________________________________

MEDICAL INFORMATION FORM

Patient name ________________________________________

Have you seen a spine surgeon for this issue? _____NO ____YES

What was recommended?_____________________________________________________

Have you Previous Spine Surgery?___NO ___YES When: ___/___/_____

Doctor:___________________________________________

TYPE OF SPINE SURGERY:

______________________________________________________________________________

If you had previous spine surgery, did the surgery make the pain better: ____YES ___NO

Have or are you planning to apply for Disability or Worker’s Compensation: ____YES ___NO

Is there a lawsuit or litigation pending in relationship to your pain? ____YES ___NO

Date of Injury: _______________________________________

REVIEW OF SYSTEMS:

Primary Reason for Today’s Visit:

________________________________________________________________________

Do you presently have any problems with the following areas? If YES, give explanation and date

Fever ____YES ____NO Weakness of Upper or Lower extremities __ YES___NO

Chills ____YES ____NO Gait imbalance ___YES___NO

Weight loss ____YES ____NO Dropping objects ___YES__ NO

H/O Falls ____YES____NO Bowel or Bladder Incontinence ___YES___NO

Eyes(eye pain, vision loss) ____YES ____NO

Ears, Nose, Mouth, Throat: ____YES ____NO

Cardiovascular, (heart, blood vessels) ____YES ____NO

Respiratory (lungs/breathing) ____YES ____NO

Gastrointestional (stomach/intestines) ____YES ____ NO

Genitourinary (genitals/kidney/bladder) ____YES ____NO

Musculoskeletal (muscles/joints) ____YES ____NO

Integument (skin/breast) ____YES ____NO

Neurological ____YES ____NO

Psychiatric (depression, anxiety, bipolar, substance abuse) ____YES ____NO

Endocrine (hormones, glands) ____YES ____NO

Hematologic/Immunologic (blood) ____YES ____NO

Do you have blood clotting problems?___YES ____NO

Excessive bleeding? ____YES ____NO

Blood loss during surgery? ____YES ____NO

Seasonal Allergies (hay fever) ____YES ____NO

Diabetes _____YES ______NO if yes, Last A1c level?___________ Date __________

Saratoga Spine

MEDICAL INFORMATION FORM

PAST MEDICAL HISTORY:

Check below if you have had any of the following:

_____ Heart Disease _____ High Blood Pressure ____ Diabetes

_____Cancer _____ Fibromyalgia ____ Tuberculosis

_____Migraine Headaches _____ Hepatitis ____ Kidney Disease

_____Emotional Disorder _____ Asthma ____ HIV

Other_________________________________________________________________________

PAST SURGERIES: (Procedure and date):______________________________________

_____________________________________________________________________________

FAMILY HISTORY (Muscle or nerve problems, Diabetes, or Bleeding Disorders):

_____________________________________________________________________________

CURRENT MEDICATIONS and DOSAGE: (Dates started meds and include non-

prescription)

______________________________________________________________________________

**ALLERGIES TO MEDICINE/SUBSTANCES/LATEX: (Include reaction)

WORK STATUS:

Employer Name and Address_____________________________________________________________________

Occupation____________________________ Duties ___________

______________________________________

Are you currently? _____ Working Full Time _____Working Part time

_____ Unemployed _____ Retired

_____ Disabled, Temp _____ Disabled, Perm

_____ Housewife

her

are

cur

ly NOT working: How long have

you been off work due to your back/neck pain?

_____________________________________

PAIN DIAGRAM:

If you have the ability to download, draw,

and scan to email, please use the following

diagrams to show us where you are

experiencing pain and numbness. If you do

not, please describe :____________________

_____________________________________

DULL___

BURNING___

COLD___

ELECTRIC TINGLING___

Saratoga Spine

Check any/all of following that describe pain.

TIGHT___ THROBBING___ SHOOTING___

MEDICAL INFORMATION FORM

Patient name_________________________________________

SOCIAL HISTORY:

Marital Status: ___Single ___Married ___Divorced ___Separated ___Widowed

Highest Education Leve

l Completed:

____ Grade school ____ High School ____ College, Technical ____ Graduate, Professional

Do you currently use Tobac

co? ___Yes ___No ______ Started Age/Total years _____Stopped

Have you ever used tobacco products? ____Yes ____No If yes, what tobacco products?_________________

Indicate quantity per day: Cigarettes____ Cigars____ Chewing Tobacco______

Do you currently consume A

lcohol? ______Yes _____No If yes, how much?________ Amount Per day

Do you have any history of recreational drug use? Current use _____Yes _____No What drug(s)_______________

Past use _____Yes _____ No What drug(s)______________

Patients with known Scoliosis or Kyphosis, please complete the next section.

SCOLIOSIS/ KYPHOSIS

Year deformity was first noticed: _________

Your age at the time deformity was first noticed: _________

Family history of Scoliosis / Kyphosis: ____ Parent _____Brother/Sister

_____None ____Cousin

______Other

Previous non-operative treatment: _____None _____Observation Only

_____ Exercise _____Brace ___ Other ______________

First operative event: ___/___/_____ Second operative event: ___/___/_____

Current concerns: ____ None ____Feel imbalance

____ New or increased back pain ____Painful rod

____ Unhappy with my appearance

If you have back pain, then where: ___Upper Back ___Mid Back ___Lower Back

Do you feel that your curves have increased or decreased over time: ___Yes ___No

Do you feel you have lost height in the last few years: ___Yes ___No

Saratoga Spine

MEDICAL INFORMATION FORM

Saratoga Spine

PATIENT NAME_____________________________________________

INSURANCE

Insurance policy holder? ______________________________________

Relationship to patient: (self, wife, etc.)_____________________________________

Policy holder’s employer_________________________________________________

Birth date: ________________________ SS# _____________________________

Health Insurance company :_____________________________________________

ID# ____________________________ Group # _______________________________

Is patient covered by secondary insurance? Y/N (If yes, Please Complete the Following)

Insurance company name: _________________________________________________

ID#: ____________________________ Group #________________________________

***WORKER’s COMPENSATION or NO FAULT INFORMATION ***

This information is Mandatory if you are filing a claim thru Workers Comp or No Fault insurance

Is patient covered by No-Fault insurance? Y/N _____

Is patient covered by Workers Compensation? Y/N _____

Onset date of Injury or accident___________________________

WC or NF Insurance company name: __________________________ Policy #___________________

WC Case ID# _________________________Group # _______________________________

Case worker’s name and phone/fax #: ___________________________________________________

__________________________________________________________________________________

Employer Name:_____________________________________________________________________

Employer Address:___________________________City______________State_____________Zip_____

Job Title: ________________________________________________________________________

Job Activity (ie; sit, stand etc)_________________________________________________________

MEDICAL INFORMATION FORM

Saratoga Spine

Patient Name ___________________________________________________________

I certify that I have insurance with the above company and assign Saratoga Spine all insurance benefits,

if any, otherwise payable to me for services rendered. I authorize use of my signature on all insurance

submissions.

The offices of Saratoga Spine may use my health care information and may disclose such information

to the above named insurance companies and their agents for the purpose of obtaining payment for

services and determining insurance benefits and the benefits payable to related services.

MEDICARE AUTHORIZATION:

I request that payment of authorized Medicare benefits be made to Dr. John Herzog for their services. I

authorize any holder of medical or other information about me to be released to Medicare or Medicaid

services and their agents any information needed to determine these benefits related to services.

_______________________________________________________________________________

Signature of Beneficiary, Guardian or Personal Representative

_______________________________________________________________________________

Print Name of Beneficiary, Guardian or Personal Representative

_____________________ ______________________________

Date Relationship to Beneficiary

TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS COMPLETE AND CORRECT. I

UNDERSTAND THAT IT IS MY RESPONSIBILTY TO INFORM SARATOGA SPINE IF I OR MY MINOR CHILD,

EVER HAVE A CHANGE IN ANY OF THE ABOVE INFORMATION

______________________________________________ __________________

Signature of Patient, Parent or Guardian Date

MEDICAL INFORMATION FORM

Saratoga Spine

Patient Name ____________________________________________

HIPPA PRIVACY STATEMENT

This notice describes how health information about you, if you decided to become a patient of this practice, may be

used, disclosed and how you can get access to your health information. This is required by the Privacy Regulations

used as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

Commitm

ent to your privacy:

This prac

tice is dedicated to maintaining the privacy of your health information. We are required by law to maintain

the integrity of your health information. We realized these laws are complicated, but we must provide you with the

following information:

1. To public he

alth authorities and health oversight agencies that are authorized by law to collect information.

2. Lawsuits and similar proceedings in response to a court order.

3. If required to do so by law enforcement official.

4. When necessary to reduce or prevent a serious threat to your health and safety or of another individual of

the public. We will only make disclosures to a person or organization able to help prevent the threat.

5. If you are a member of the US Military forces and if required by the appropriate authorities.

6. To federal officials for intelligence and national security activities authorized by law.

7. For Workers Compensation and similar programs.

Rights regarding your health information:

You can request that our practice communication with you about your health in a particular manner. We will

accommodate reasonable requests.

1. You can re

quest a restriction in our use or disclosure of your health information for treatment and payment

of health care operations.

2. You have the right to inspect and obtain a copy of your health information that may be used to make

decisions about you, including patient medical records and billing records, but not including psychotherapy notes.

You must submit your request in writing to your physician's name to 7 Murray Street, Glens Falls, NY 12801. We

will respond within ten (10) business days.

3. You may ask to amend your health information if you believe it is incorrect or incomplete, as longs as the

information is kept by our practice. To request and amendment, your request must be made in writing and submitted

to this office. You must provide us with a reason that supports your request for amendment.

4. Right to a copy of this notice.

5. Right to file a complaint if you believe your privacy rights have been violated, you may file a complaint

with our practice or with the Secretary of the Department of Health and Human Services. All complaints must be

submitted in writing. You will not be penalized for filing a complaint.

6. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written

authorization for uses and disclosure that are not identified by this notice or permitted by applicable law.

This practice shares an electronic medical record database. We do cover each other and your medical records will be

accessed when necessary.

Additional person(s) authorized to speak with regarding appointment messages and/or medical information:

Name:_____

______________________________ Relationship:______________________________

Name:_____

______________________________ Relationship:______________________________

Signature_______________________________________Date_________________

MEDICAL INFORMATION FORM

Saratoga Spine

Patient Name ______________________________________________

Financial Responsibility

You must present a valid insurance card and photo ID such as a valid Driver’s license at each

visit. It is your responsibility to report any insurance changes to the office as soon as possible.

Any information that is inaccurate or received after the date of service may not be billable to

the insurance carrier and may become the responsibility of the account guarantor.

All co-payments and past due balances are due at time of check-in. We accept cash, check or

credit cards. Absolutely no post-dated checks will be accepted.

If your insurance pays you directly for services rendered by us, you agree to forward the

payment to us immediately.

There is a $25 service charge for all returned checks.

There is a $25.00 fee for all visit cancelled with less than 24-hour notice.

If you have any questions regarding this notice or our health information privacy policies, please

contact our office at (518) 743-1010.

Acknowledgment that I have received that above policy:

Name_____________________________________________

Signature_______________________________________Date_______

MEDICAL INFORMATION FORM

SARATOGA SPINE

PAIN MEDICATION AND CONTROLLED SUBSTANCE POLICY

Pain medication will be prescribed when necessary, in the immediate post-operative

period only. Narcotics are usually prescribed for no longer than 6-8 weeks for a non-

deformity surgery such as Laminectomy, Discectomy or Cervical Fusion. Narcotics will

usually be prescribed for no longer than 12 weeks for a lumbar spinal fusion.

Most research has shown worse outcomes for patients who are on chronic narcotics.

However, some pain specialists still routinely prescribe these medicines for prolonged

periods of time. This requires specialized expertise and close follow up by a pain

management specialist.

All Prescription refill requests must be made by the patient only and will be processed

during normal business hours. We require at least 48 hours notice. Please plan ahead.

Controlled substance medications may not be renewed if stolen or lost until the

prescription has expired.

All prescriptions will be electronically transmitted to your pharmacy. When requesting a

medication refill, please state the pharmacy you would like the prescription electronically

sent to along with your name, date of birth, medication name requested. Your request will

be reviewed by our providers and you will get a return phone call notifying you of the

status of your request.

I agree to the following and understand that I may be discharged from Saratoga Spine if I

break any of these conditions:

I will not attempt to get pain medication from any person or healthcare provider not

authorized my Saratoga Spine provider.

I will not use medication in a way that is not prescribed.

I will not exhibit deceitful behavior nor provide false

information

I will not make calls after hours to obtain medication.

I will not sell or give my medications to any other person.

I will sign and follow the "Patient Understanding for Opioid Treatment

Form"

I will sign and follow the "Patient Informed Consent for Opioid

Treatment form"

I am aware that I may be subjected to random testing including but not limited to: urine

screening and random pill counts.

Acknowledge that I have read the all the pages and agree to comply

with Saratoga Spine's Pain Medication and Controlled Substance Policy. I understand that

failure to follow these policies may result in my being discharged from Saratoga Spine and I

could risk prosecution as directed by state and federal agencies.

Patient or Guardian Signature Date:

Oswestry Low Back Pain Scale

Name________________________ Signature_________________________Date____________

Please rate the severity of your pain by circling a number below:

1 2 3 4 5 6 7 8 9 10

No pain 0 Unbearable pain

Please read: This questionnaire has been designed to give the doctor information on how your back pain has affected

your ability to manage in everyday life. Please answer every question, and circle only the one statement in each

section that applies to you. While you may consider that two of the statements in any one section relate to you,

please check just the one which most closely describes your situation.

_____________________________________________________________________________________________

Section 1 – Pain Intensity

Section 2 – Personal Care (Washing, Dressing, etc.)

0. I would not have to change my way of washing or

dressing in order to avoid pain.

1. I do not normally change my way of washing

or dressing even though it causes some pain.

2. Washing and dressing increase the pain but I manage

not to change my way of doing it.

3. Washing and dressing increase the pain and I find it

necessary to change my way of doing it.

4. Because of the pain I am unable to do some washing

and dressing without help.

5. Because of the pain I am unable to do any washing

and dressing without help.

Section 6 – Standing

0. I can stand as long as I want without pain.

1. I have some pain on standing but it does not increase with time.

2. I cannot stand for longer than 1 hour without increasing pain.

3. I cannot stand for longer than ½ hour without increasing pain.

4. I cannot stand for longer than 10 minutes without increasing pain.

5. I avoid standing because it increases the pain immediately.

Section 7 – Sleeping

0. I get no pain in bed.

1. I get pain in bed but it does not prevent me from sleeping well.

2. Because of pain my normal nights sleep is reduced by less than

one-quarter.

3. Because of pain my normal nights sleep is reduced by less than

one-half.

4. Because of pain my normal nights sleep is reduced by less than

three-quarters.

5. Pain prevents me from sleeping at all.

Section 3 – Lifting

Section 8 – Social Life

but I can manage if they are conveniently positioned

Pain has restricted my social life and I do not go out very often.

e.g., on a table.

Pain has restricted my social life to my home.

Pain prevents me lifting heavy weights but I can

I have hardly any social life because of the pain.

manage light to medium weights if they are conveniently

positioned.

I can only lift very light weights at most.

Section 4 – Walking

Section 9 – Traveling

I have no pain walking.

I get no pain when traveling.

I have some pain walking but it does not increase

I get some pain when traveling but none of my usual forms of

with distance.

travel make it any worse.

I cannot walk more than 1 mile without increasing pain.

I get extra pain while traveling but it does not compel me to

I cannot walk more than ½ mile without increasing pain.

seek alternative forms of travel.

I cannot walk more than ¼ mile without increasing pain.

3. I get extra pain while traveling which compels to seek alternative

I cannot walk at all without increasing pain.

forms of travel.

Pain restricts me to short necessary journeys under ½ hour.

5. Pain restricts all forms of travel.

Section 5 – Sitting

Section 10 – Changing Degree of Pain

I can sit in any chair as long as I like.

My pain is rapidly getting better.

I can sit only in my favorite chair as long as I like.

My pain fluctuates but is definitely getting better.

Pain prevents me from sitting more than 1 hour.

My pain seems to be getting better but improvement is slow.

Pain prevents me from sitting more than ½ hour.

My pain is neither getting better or worse.

Pain prevents me from sitting more than 10 minutes.

My pain is gradually worsening.

I avoid sitting because it increases pain immediately.

My pain is rapidly worsening.

__ __

0. I can lift heavy weights without extra pain. 0. My social life is normal and gives me no pain.

1. I can lift heavy weights but it gives extra pain. 1. My social life is normal but it increases the degree of pain.

2. Pain prevents me lifting heavy weights off the floor. 2.

Pain has no significant effect on my social life apart from limiting

3. Pain prevents me lifting heavy weights off the floor, my more energetic interests, e.g., dancing, etc.

0. The pain comes and goes and is very mild.

1. The pain is mild and does not vary much.

2. The pain comes and goes and is moderate.

3. The pain is moderate and does not vary much.

4. The pain comes and goes and is severe.

5. The pain is severe and does not vary much.

NECK DISABILITY INDEX

Please rate t

he severity of your pain by circling a number below:

No pain 0 1 2 3 4 5

7 8 9 10 Unbearable pain

Please

read: This questionnaire has been designed to give the doctor information on how your neck pain has affected

your ability to manage in everyday life. Please answer every question, and circle only the one statement in each

section that applies to you. While you may consider that two of the statements in any one section relate to you,

please check just the one which most closely describes your situation.

_____________________________________________________________________________________________

Section 1 – Pain Intensity

0. I have no pain at the moment.

1. The pain is mild at the moment.

2. The pain comes and goes and is moderate.

3. The pain is moderate and does not vary much.

4. The pain comes and goes and is severe.

5. The pain is severe and does not vary much.

Section 6 – Concentration

0. I can concentrate fully when I want to with no difficulty.

1. I can concentrate fully when I want to with slight difficulty.

2. I have a fair degree of difficulty in concentrating when I want to.

3. I have a lot of difficulty in concentrating when I want to.

4. I have a great deal of difficulty in concentrating when I want to.

5. I cannot concentrate at all.

Section 2 – Personal Care (Washing, Dressing, etc.)

Section 7 – Work

I can look after myself without causing extra pain.

I can do as much work as I want to.

I can look after myself normally but it causes extra

I can only do my usual work, but no more.

pain.

I can do most of my usual work, but no more.

It is painful to look after myself and I am slow and

I cannot do my usual work.

careful.

I can hardly do any work at all.

3. I need some help, but manage most of my personal care. 5. I cannot do any work at all.

4. I need help every day in most aspects of self-care.

5. I do not get dressed; I wash with difficulty and stay in bed.

Section 3 – Lifting

0. I can lift heavy weights without extra pain.

1. I can lift heavy weights but it causes extra pain.

2. Pain prevents me lifting heavy weights off the

floor, but I can if they are conveniently positioned,

e.g. on the table.

3. Pain prevents me from lifting heavy weights, but

I can manage light to medium weights if they are

conveniently positioned.

4. I can lift very light weights.

5. I cannot lift or carry anything at all.

Section 8 – Driving

0. I can drive my car without neck pain.

1. I can drive my car as long as I want with slight pain in my neck.

2. I can drive my car as long as I want with moderate pain in

my neck.

3. I cannot drive my car as long as I want because of moderate pain

in my neck.

4. I can hardly drive my car at all because of severe pain in my neck.

5. I cannot drive my car at all.

Section 4 – Reading

0. I can read as much as I want to with no pain in my

neck.

1. I can read as much as I want with slight pain in

my neck.

2. I can read as much as I want with moderate pain

in my neck.

3. I cannot read as much as I want because of moderate

pain in my neck.

4. I cannot read as much as I want because of severe

pain in my neck.

5. I cannot read at all.

Section 5 – Headache

0. I have no headache at all.

1. I have slight headaches which come infrequently.

2. I have moderate headaches which come infrequently

3. I have moderate headaches which come frequently.

4. I have severe headaches which come frequently.

5. I have headaches most of the time.

Section 9 – Sleeping

0. I have no trouble sleeping.

1. My sleep is slightly disturbed (less than 1 hour sleepless).

2. My sleep is mildly disturbed (1-2 hours sleepless).

3. My sleep is moderately disturbed (2-3 hours sleepless).

4. My sleep is greatly disturbed (3-5 hours sleepless).

5. My sleep is completely disturbed (5-7 hours sleepless).

Section 10 - Recreation

0. I am able to engage in all recreational activities with no pain in

my neck.

1. I am able to engage in all recreational activities with some pain in

my neck.

2. I am able to engage in most, but not all recreational activities

because of pain in my neck.

3. I am able to engage in a few of my usual recreational activities

because of my neck pain.

4. I can hardly do any recreational activities because of pain in my

neck.

5. I cannot do any recreational activities at all.

___

___ ___ ___

___

___ ___

___

Name_______________________________Signature_______________________________Date_______________

Over

2 weeks, how of

en have you been

hered by

he fo

ng prob

ems?

1. Fee

ng nervous, anx

ous, or on edge

2. No

ng ab

o s

op or con

worry

3. Worry

oo much abou

fferen

ngs

4. Troub

e re

5. Be

ng so res

ess

's hard

o s

till

6. Becom

ng eas

y annoyed or

7. Fee

ng afra

d as

f some

ng awfu

happen

Add

he score

or each co

umn

Score (add your co

umn scores) =

Severa

Over ha

Near

sure

days

he days

every day

If you checked off any prob

ems, how d

have

hese made

for you

o do your work,

ake

care of

ngs a

home, or ge

ong w

h o

her peop

Not difficult at all

Somewha

Very difficult

reme

y d

Name_______________________ Date________________

Generalized Anxiety Disorder 7-item (GAD-7) scale

) - p a s 9 )

If you checked off any problems, how difficult have these problems made it for you to do your

work, take care of things at home, or get along with other people?

Not

difficult

all



Somewhat

difficult



Very

difficult



Extremely

difficult



Over the last 2 weeks, how often have you been bothered

by any of the following problems?

(Use “✔” to indicate your answer)

Not at all

Several

days

than half

the days

Nearly

every

day

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself — or that you are a failure or

have let yourself or your family down

7. Trouble concentrating on things, such as reading the

newspaper or watching television

8. Moving or speaking so slowly that other people could have

noticed? Or the opposite — being so fidgety or restless

that you have been moving around a lot more than usual

9. Thoughts that you would be better off dead or of hurting

yourself in some way

PATIENT HEALTH QUESTIONAIRE (phq-9)

NAME________________________________ DATE

______________________

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Dr. John C. Herzog Dr. Armin Afsar-Keshmiri Dr.

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