EFTA00313814.pdf

Name: DOB: CAD ColumbiaDoctors Adult New Patient Intake Form Patient Information Last Name: -P3 -7 First Name: RG-\) Ce_rp DOB: 1 -/LL Zia 195 3 Gender: 1\A Home Phone: Mobile Phone: Preferred Phone: Home or obile (circle one) Email: jev a_ca.41 / ; 1• aenn 9 One:14 Emergency Contact: KArgyNiA SWALIAK. Relationship: Fai e l .Jh Emergency Contact Phone: Patient Marital Status: SIAG LE Occupation: BA )..1 g, Employer: s -re- scumieg,..1 . Primary Care Provider (PCP): I .40 .1-re..D OCAL--(14 e AgE PCP Phone: - 2'4-44) Referring Provider: be H AR g•/ FISCH Referring Phone: Preferred Pharmacy: y TA I-IE ACTS Pharm Phone: 2I - 111O Preferred Pharmacy Address: 23S 1st AVE. errWr-1 (.46"4 ? (.91-7) /\1`) Please list ALL active treating physicians (i.e. pulmonologist, oncologist, internist, cardiologist, etc...) Doctor's Name: T)P.-. SH or.r) Specialty: A 42bl OL.-0CIZ-r Doctor's Name: Die • 6 IZUCE: DZKOVI/fri- Specialty: II4Tegi.113-r Doctors Name: Specialty: Doctor's Name: Specialty: Collection of the following information is encouraged by federal health agencies. This information is used to monitor and improve the quality of care provided to all patients. Ethnicity: Race: o Decline Response o Decline Response 0 Black or African American o Hispanic or Latino ..Pr American-Indian or Alaska Native a Native Hawaiian or Pacific Islander Not Hispanic or Latino o Asian c Other Preferred Language: o Decline Response Patient Financial Obligation Agreement I understand that all applicable copayments and deductibles are due at the time of service. I agree to be financially responsible and make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to ColumbiaDoctors for services rendered. I authorize representatives of Columbia Doctors to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. Notice of Privacy Practices: Acknowledgement of Receipt I acknowledge that I was provided with a copy of the Columbia Doctors Notice of Privacy Practices (NOPP). Received o N/A (only if you received the notice from ColumbiaDoctors previously) Information Disclosure and Consent ColumbiaDoctors will provide you with the health plans that your provider(s) accepts*. If you decide to be treated by a provider who does not accept your health plan, you will be asked to sign a consent form agreeing that you accept treatment from that provider. I read and agree to all of the above (Financial Agreement, Notice ofPrivacy, Insurance Information). -TE,Firiezy 11.1 Patient or Legal Guardian Name (Print): Patient or Legal Guardian Signature: — Date: Feb • H-10_01 p *Please refer to our website: columbiadoctors.org, for a list of insurances accepted by your provider. Version 1.8 Page 1 of 14 Updated: 6/2212016 EFTA00313814  Name: DOB: Columbia Doctors Reason for today's visit: General Medical Questionnaire Have you EVER had any of the following? Asthma/Breathing Problems oY oN Heart Disease/Disorder oY oN Arthritis oY oN Lung Disorder oY oN Bleeding/Clotting Disorder oY oN Liver Disease ❑Y ❑N Blood Pressure Disorder oY oN Neurological Disorder/Chronic Headaches. oY oN Blood Transfusion ❑Y oN Psychiatric Disorder/Illness oY oN Bowel/Stomach Problems oY oN Pulmonary Embolism/DVT oY oN Cancer oY oN Stroke oY oN Cholesterol Disorder 0Y oN Seizure or Epilepsy ❑Y oN Diabetes oY oN Thyroid Disorder oY oN Eye Disorder (i.e. Glaucoma, cataract) oY oN Urinary/Kidney Disorder oY oN Women Only: Gynecological Issues oY ❑N Please list any other medical illnesses or problems and provide details for any of the above conditions: Please list all eries and hos• italizations and the a oximate date. Procedure/ Hospitalization Date Please indicate any major conditions/illnesses that your immediate family members have had: Relative Condition and description Living? If deceased, at what age? Mother oY oN Father oY oN Sibling oY oN Other: oY oN Do you currently smoke? in Y oN If no, previously? oY a N Years smoked Packs/day Do you use other tobacco products? oY o N Consume alcohol? oY oN If yes, drinks/week: Women Only: Any past pregnancies? to Y o N How many? How many deliveries? Version 1.8 Page 2 of 14 Updated: 6/224016 EFTA00313815  Name: DOB: Cit? ColumbiaDoctors Do you have any allergies to medications or other substances (pets, food, etc.)? ❑Y ❑N If es, lease list aller. ies and reactions (includin rash, hives throat swellin., ana •h laxis): Allergy Reaction Reaction Please list ALL of our current medications, includin over the counter medications su lements and herbs: Medication Name Medication Name Review of Systems Please indicate ALL that you have experienced within the past 6 - 12 months. Constitutional ❑YON Fever oYoN Fatigue OYON Weight Gain (_Lbs) OYON Sleep Disturbances OYON Chills OYON Feeling Poorly OYON Weight Loss (_ Lbs) ❑ Other: OYON Sweats OYON Unexp. weight Change Head, Eyes, Ears, Nose, and Throat ❑YON Vision Problem OYON Red Eyes OYON Congestion OY❑N Hoarseness OYON Decreased Hearing OYON Eye Pain OYON Snoring OYoN Ringing in Ears OYON Double Vision ❑YON Runny Nose OYON Dry Mouth OYON Vertigo DYON Light Sensitivity OVEN Neck Stiffness OYON Flu-Like Symptoms OYON Earache OYON Itchy Eyes OYON Nosebleed OYON Sore Throat OYON Other: Cardiovascular OYON Chest Pain OYON Cold Extremities OYON Irregular Heart Rhythm OYON Palpitations OYON Cold Hands or Feet ❑YON Other: OYON Leg Swelling OYON Leg Pain w/ Walking Respiratory DYON Shortness of Breath OYON Wheezing ❑YON Coughing Up Blood O OYON Cough OYON Shortness of Breath ❑YON Coughing Up Sputum DYON Rapid Breathing OYON Chest Congestion ❑ Other: Gastrointestinal OYON Abdominal Pain OYON Diarrhea ❑YON Change in Bowels ❑YON Painful Swallowing OYON Blood in Stool OYON Black/Tarry Stools ❑YON Vomiting Blood O Other: OYON Vomiting OYON Decreased Appetite OYON Bowel Incontinence ❑YON Nausea OYON Yellow Skin OYON Rectal Pain Version 2.8 Page 3 of 14 Updated: 6/2212016 EFTA00313816  Name: DOB 42— ColumbiaDoctors DYON Constipation OYON Trouble Swallowing MTh Heartburn Neurological OYON Headache OYON Unsteady OYON Numbness oYoN Tremor OYON Dizziness OYON Disorientation [WON Tingling OYON Memory Lapses/Loss OYON Decreased Strength OYON Confusion OYON Seizures O Other: OWN Poor Coordination OYON Burning Sensation OYON Fainting (Syncope) Musculoskeletal OYON Joint Pain OYON Limb Pain OWN Muscle Pain O Other: OYON Neck Pain OYON Joint Swelling OYON Muscle Weakness OYON Back Pain OYON Muscle Cramps ONION Leg Swelling Genitourinary OYON Frequent Urination OYON Pelvic Pain OYON Painful Intercourse OYON Heavy Period Bleeding OWN Incontinence OYON Nocturia OYON Discharge- Vaginal ❑ Other: OYON Urinary Urgency OYON Itching- Genital OWN Vaginal Bleeding OYON Painful Urination OYON Change in Libido oYoN Irreg. Monthly Cycles Integumentary MEIN Rash OYON Skin Wound OYON Unusual Growth OYON Skin Cancer OYON Dry Skin OYON Change in A Mole OYON Itching o Other: Psychiatric OWN Depression OYON Anxiety oOther: Hematologic/Lymphatic OWN Easy Bruising OYON Easy Bleeding OVON Swollen Lymph Nodes ❑ Other: Endocrine DYON Excessive Thirst DYON Heat Intolerance OYON Changes- Skin oYoN Cold Intolerance DYON Changes- Hair o Other: OFFICE USE ONLY: Provider Signature: Date: Version LS Page 4 of 14 Updated: 6/22)2016 EFTA00313817  CI? ColumbiaDoctors I Orthopedics Office Use Only MRN N: Age: Height: Additional Orthopedic Department Form Weight: Pulse: BP: BMI: Name of person completing form: JE.-F-Fe essisit-i Re ationship (if n • Referring 's name: "Ni2• 1,1`lnne-4-1 Phone num • Address: /441-PA 1-)A04-`9 Aft' t 1 1•1. Fax number: Would you like o copy o) today's consult note sent to this doctor?Bies ci No Primary care provider's name:ba taveE mccgow I T2- Phone number West PAL-m Address: 1+11 k . FL-Aet el "r a2. elite rt. Faxecmo number: Would you like o copy of todoy's consult note sent to this doctor? 0 yes 0 No 3 aq'Ol Reason for today's visit: Which side hurts? 0 Left O Right 0 Both How long has your reason for today's visit been going on? How did it start? Hand dominance: 0 Left 0 Right Pain description: ElDull O Sharp ['Tingling p Other: When does pain occur? 0 At rest ['With activity O At night O Other: Rate pain: (Check box) 1 2 3 4 5 6 7 8 9 No pain 10 Most 0 0 0 0 Cl 0 0 extreme What reduces the pain? 0 Medicine 0 Ice 0 Heot O Rest ❑ Elevation Your problem has: 0 Improved 0 Worsened Any other symptoms associated with the current problem? Does your home have: (Check all that apply) [11story 0 2 stories 03+ stories OEntrance steps 0 Elevator Do you take public transportation? 0 Y ON Do you exercise regularly? OY ON Are you involved in organized sports? 0 N r Required Information: — i Did this injury happen while working? 0 Yes 0 No Does this injury relate to an auto accident? 0 Yes 0 No Is this injury related to a pending lawsuit? 0 Yes 0 No Patient Signature rig 11-1-,aols7 Date Couistau Likivkasrry MinicAl. CENTER NewYork-Presbyterian Page 5 of 14 Updated 3/29/17 EFTA00313818 CI' ColumbiaDoctors I Orthopedic Surgery Adult Spine Supplement Spine PLEASE USE BLUE OR BLACK INK ONLY NAME: TO Fr- aa- ). c-.irs-rei4 DATE OF BIRTH: I -20-53 DATE: FaS 172 019 I. Chief complaint O Spinal Deformity (Scoliosis, Kyphosis, Flatback Syndrome, etc.) (check all that apply): O Neck pain Arm: O Pain O Numbness O Weakness O Back pain Leg: O Pain O Numbness O Weakness Other 2. If recommended, please rate how interested you are in having surgery to treat your problem: 0 5 10 I I I I I I Not at all Maybe Definitely A. ALL PATIENTS SHOULD ANSWER THE FOLLOWING***** I. Coughing or sneezing O Increases O Sometimes increases O Does not increase the pain. 2. There is: O No loss of bowel or bladder control O Loss of bowel or bladder control since 3. I have: O Not missed any work because of this problem O Missed (how much?) work. 4. Treatments have included: O No medicines, therapy, manipulations, injections, or braces Neck Back Neck Back ❑❑❑❑❑❑❑ O Physical therapy, exercise O O Anti-inflammatory medications O Massage & ultrasound O O Narcotic medication O Traction O O Epidural steroid injections times which O Manipulation relieved the pain for (how long)? O Tens Unit O O Trigger point injections times which O Shoulder injections relieved the pain for (how long)? O Braces O O Other 5. Generally speaking, are your symptoms getting better or worse? (Fill in no e circle) O Getting much better O Getting somewhat better O Staying about the same O Getting somewhat worse O Getting much worse 6. If you had to spend the rest of your life with the symptoms you have right now, how would you feel about it? (Fill in one circle) OVery dissatisfied °Somewhat dissatisfied ONeutral °Somewhat satisfied OVery satisfied MY PAIN / DISCOMFORT IS: 0 1 2 3 4 5 6 7 8 9 10 (circle number) I No Pain 1 Slighi I I Mild 1 I Moderate 1 I I 1 I Severe Excruciating Pain as bad as it could be CONTINUED ON NEXT PAGE Page 6 of 14 EFTA00313819  Adult Spine Supplement Cil? ColumbiaDoctors I Orthopedic Surgery Spine NAME: jecir-gEN aPSIEIti DATE OF BIRTH: Si? DATE: FCIS ilk 02-012 ACHING 0 No 3 Yes Please fill in drawings: (shade the areas) LIFT LEFT RIGHT STABBING PAIN 0 No 0 Yes My main goal(s) today is (are) to get (check all that apply): ❑ Second opinion ❑ Recommendation for Physical therapy O Medications ❑ Injection treatments O Surgery If you have seen other surgeons for this problem and were not happy, why? O Didn't answer my questions O Had no suggestions on what to do ❑ Personality issues O Office staff problems O Spent too little time with me O Other CONTINUED ON NEXT PAGE Page 7 of 14 EFTA00313820  Adult Spine Supplement CI? ColumbiaDoctors I Orthopedic Surgery Spine NAME: JER-r---gc-A DATE OF BIRTH: DATE: B. For patients with NECK OR ARM problems: DON'T DO IF BEING SEEN FOR A BACK PROBLEM I. What % of your pain is neck pain and what % is arm pain? (check appropriate box) O Neck 0%, Arm 100% O Neck 10%, Arm 90% O Neck 25%, Arm 75% O Neck 40%, Arm 60% O Neck 50%, Arm 50% O Neck 60%, Arm 40% O Neck 75%, Arm 25% O Neck 90%, Arm 10% ❑ Neck 100%, Arm 0% 2. There is: O No arm pain O Arm pain is as follows (check the following): a. O Right 0%, Left 100% O Right 10%, Left 90% O Right 25%, Left 75% O Right 40%, Left 60% O Right 50%, Left 50% O Right 60%, Left 40% 0 Right 75%, Left 25% O Right 90%, Left 10% O Right 100%, Left 0% b. The arm pain is present in the (check the following): Right: O Upper back 0 Shoulder O Upper arm O Forearm O Hand/finger Left: O Upper back O Shoulder O Upper arm O Forearm O Hand/finger 3. Raising the arm: O Improves the pain O Worsens the pain ❑ Does not affect the pain 4. Moving the neck: O Improves the pain O Worsens the pain O Does not affect the pain 5. There is: O No weakness of the arms and hands O Weakness of the (check the following): Right: O Shoulder O Upper arm O Forearm ❑ Hand/finger Left: O Shoulder O Upper arm O Forearm O Hand/finger 6. There is: O No numbness of the arms and hands O Numbness of the (check the following): Right: O Upper arm O Forearm O Thumb O Index finger O Long finger O Ring finger O Small finger Left: O Upper arm O Forearm O Thumb O Index finger O Long finger O Ring finger O Small finger 7. There ( O is O is no) difficulty picking up small objects like coins or buttoning buttons. 8. There ( O is a O is no) problem with balance or tripping frequently. 9. There are: ( O Frequent O Occasional O No) headaches in the back of the head. Patients with HEADACHES. I. If you have headaches, how would you describe their intensity and frequency? I have (check one): 0 slight Omoderate 0 severe headaches They come (check one): 0 infrequently O frequently O almost all the time 2. The headaches are located (check the following): a. O In the back of my neck b. O In the back of my head c. O The side of my head/temple area d. O In the front of my head (near my eyes) 3. How long have you suffered from headaches? O Several days O Several weeks O Several months O Greater than I year 4. When do the headaches occur most commonly? O Morning O Afternoon O While at work O Evening O No pattern 5. What is your average headache pain level throughout the day? (please circle) 0 1 2 3 4 5 6 7 8 9 10 6. How would you describe your pain? O Throbbing O Squeezing O Pressure O Dull O Stabbing O Shooting 7. What medications (either prescription or over-the-counter) do you take for your headaches? CONTINUED ON NEXT PAGE Page 8 of 14 EFTA00313821  Adult Spine Supplement gig ColumbiaDoctors I Orthopedic Surgery Spine Name: -3 7 e.-FP- 6 ‘) Ggs-rfr..) DOB: -1 9- S3 DATE: Z +- it? THE NECK DISABILITY INDEX This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage everyday activities. It is important that you answer each of the following questions. We realize that you may feel that more than one statement may relate to you, but please circle the ONE BEST ANSWER to each question which closely describes your problem right now. Pain Intensity Reading 0. I have no pain at the moment 0. I can read as much as I want to with no pain in my 1. The pain is mild at the moment. neck. 2. The pain comes and goes and Is moderate. 1. I can read as much as I want with slight pain in my 3. The pain is moderate and does not vary much. neck. 4. The pain is severe but comes and goes. 2. I can read as much as I want with moderate pain in S. The pain is severe and does not vary much. my neck. 3. I cannot read as much as I want because of Personal Care moderate pain in my neck. 4. I cannot read as much as I want because of severe 0. I can look after myself without causing extra pain. pain in my neck. 1. I can look after myself normally but it causes extra 5. I cannot read at all. pain. 2. It is painful to look after myself and I am slow and Headache careful. 3. I need some help, but manage most of my personal 0. I have no headaches at all. care. 1. I have slight headaches which come infrequently. 4. I need help every day in most aspects of self-care. 2. I have moderate headaches which come in- S. I do not get dressed; I wash with difficulty and stay frequently. in bed. 3. I have moderate headaches which come frequently. 4. I have severe headaches which come frequently. Lifting 5. I have headaches almost all the time. 0. I can lift heavy weights without extra pain. Concentration 1. I can lift heavy weights, but it causes extra pain. 2. Pain prevents me from lifting heavy weights off the 0. I can concentrate fully when I want to with no floor but I can if they are conveniently positioned, difficulty. for example on a table. 1. I can concentrate fully when I want to with slight 3. Pain prevents me from lifting heavy weights, but I difficulty. can manage light to medium weights if they are 2. I have a fair degree of difficulty in concentrating conveniently positioned. when I want to. 4. I can lift very light weights. 3. I have a lot of difficulty in concentrating when I 5. I cannot lift or carry anything at all. want to. 4. I have a great deal of difficulty in concentrating when I want to. S. I cannot concentrate at all. CONTINUED ON NEXT PAGE Page 9 of 14 EFTA00313822  Adult Spine Supplement gb ColumbiaDoctors I Orthopedic Surgery Spine Work Sleeping 0. I can do as much work as I want to. 0. I have no trouble sleeping 1. I can only do my usual work, but no more. 1. My sleep is slightly disturbed (less than 1 hour 2. I can do most of my usual work, but no more. sleepless). 3. I cannot do my usual work. 2. My sleep is mildly disturbed (1-2 hours sleepless). 4. I can hardly do any work at all. 3. My sleep is moderately disturbed (2-3 hours 5. I cannot do any work at all. sleepless). 4. My sleep is greatly disturbed (3-5 hours sleepless). Driving 5. My sleep is completely disturbed (5-7 hours sleepless). 0. I can drive my car without neck pain. 1. I can drive my car as long as I want with slight pain Recreation in my neck. 2. I can drive my car as long as I want with moderate 0. I am able engage in all recreational activities with pain in my neck. no pain in my neck at all. 3. I cannot drive my car as long as I want because of 1. I am able engage in all recreational activities with moderate pain in my neck. some pain in my neck. 4. I can hardly drive my car at all because of severe 2. I am able engage in most, but not all recreational pain in my neck. activities because of pain in my neck. 5. I cannot drive my car at all. 3. I am able engage in a few of my usual recreational activities because of pain in my neck. 4. I can hardly do any recreational activities because of pain in my neck. 5. I cannot do any recreational activities at all Office Use Only: Score Z'I'P-1Q Physician Signature and Date Patient Signature and Date CONTINUED ON NEXT PAGE Page 10 of 14 EFTA00313823 QID. ColumbiaDoctors I Orthopedic Surgery Adult Sphie Supplement NAa ille 4/1 ePSTEW IC51 DATE OF BIRTH: kV ) gg DATE: 2- - rk—kr C. For patients with BACK OR LEG Problems: DON'T DO IF BEING SEEN FOR A NECK PROBLAV I. What % of your pain is back pain and what % is leg or buttock pain? (check appropriate box): O Back 0%, Leg 100% O Back 10%, Leg 90% O Back 25%, Leg 75% O Back 40%, Leg 60% ❑ Back 50%, Leg 50% O Back 60%, Leg 40% O Back 75%, Leg 25% O Back 90%, Leg I 0% ❑ Back 100%, Leg 00/0 2. There is: O No leg pain O Leg pain as follows (check the following): a. O Right 0%, Left 100% O Right 10%, Left 90% O Right 25%, Left 75% O Right 40%, Left 60% ❑ Right 50%. Left 50% ❑ Right 60%, Left 40% O Right 75%. Left 25% O Right 90%. Left 10% ❑ Right 100%, Left 0% b. The pain is present in the (check the following): Right: O Buttock O Thigh-front O Thigh-back O Calf O Foot Left: O Buttock O Thigh-front O Thigh-back O Calf O Foot 3. There is: O No weakness of the legs O Weakness of the (check the following): Right: O Thigh O Calf O Ankle O Foot O Big toe Left: O Thigh O Calf O Ankle O Foot O Big toe 4. There is: O No numbness of the legs O Numbness of the (check the following): Right: O Thigh O Calf O Foot Left: O Thigh O Calf O Foot 5. The worst position for the pain is: O Sitting O Standing O Walking 6. How many minutes can you stand in one place without pain? O 0-10 O 15-30 O 30-60 O 60+ 7. How many minutes can you walk without pain? O 0-10 O 15-30 O 30-60 O 60+ 8. Lying down: O Eases the pain O Does not ease the pain O Sometimes eases the pain 9. Bending forward: O Increases the pain O Decreases the pain O Doesn't affect the pain In the past week, how often have you suffered: (Please circle the number that applies) None of A little of Some of A good bit Most of All of the time the time the time of the time the time the time 10. Low back and/or buttock pain 2 3 4 5 6 11. Leg pain 2 3 4 5 6 12. Numbness or tingling in leg and/or foot 2 3 5 4 6 13. Weakness in leg and/or foot (such as difficulty lifting foot) I 2 3 4 5 6 In the past week, how bothersome have these symptoms been? (Please circle the number that applies) Not at all Slightly Somewhat Moderately Very Extremely bothersome bothersome bothersome bothersome bothersome bothersome 14. Low back and/or buttock pain 2 3 4 5 6 15. Leg pain 1 2 3 4 5 6 16. Numbness or tingling in leg and/or foot 1 2 3 4 5 6 17. Weakness in leg and/or foot (such as difficulty lifting foot) 1 2 3 4 5 6 CONTINUED ON NEXT PAGE Page 11 of 14 EFTA00313824 di ColumbiaDoctors I Orthopedic Surgery Adult Spine Supplement Spine For patients with a SPINAL DEFORMITY/ BACK CURVATURE. 1. How was your spinal deformity discovered? 2. Do you know your present curve measurement(s)? 3. Rcason(s) for seeking treatment at this time: ❑ progressive deformity ❑ pain ❑ can't stand straight ❑ I don't like the appearance of my back/waistline ❑ Other: CONTINUED ON NEXT PAGE Page 12 of 14 EFTA00313825  Adult Spine Supplement Cifg ColumbiaDoctors I Orthopedic Surgery Spine Name: ,Teree`i c-PS-rEilJ DOB: I —20"53 DATE: 2- iti--15? THE BACK DISABILITY INDEX This questionnaire is designed to enable us to understand how much your back pain has affected your ability to manage everyday activities. It is important that you answer each of the following questions. We realize that you may feel that more than one statement may relate to you, but please circle the ONE BEST ANSWER to each question which closely describes your problem right now. Pain Intensity Walking 0. I can tolerate the pain I have without having to use 0. Pain does not prevent me from walking any pain killers. distance. 1. The pain is bad but I manage without taking pain 1. Pain prevents me walking more than 1 mile. killers. 2. Pain prevents me walking more than 1/2 mile. 2. Pain killers give complete relief from pain. 3. Pain prevents me walking more than 1/4 mile. 3. Pain killers give moderate relief from pain. 4. I can only walk using a stick or crutches. 4. Pain killers give very little relief from pain. 5. I am in bed most of the time and have to crawl to 5. Pain killers have no effect on the pain, I do not use the toilet. them. Personal Care (Washing, Dressing, etc.j Sitting 0. I can look after myself normally without it causing 0. I can sit in any chair as long as I like. extra pain. 1. I can only sit in my favorite chair as long as I like. 1. I can look after myself normally but it causes extra 2. Pain prevents me from sitting more than one hour. pain. 3. Pain prevents me from sitting more than thirty 2. It is painful to look after myself and I am slow and minutes. careful. 4. Pain prevents me from sitting more than ten 3. I need some help but manage most of my personal minutes. care. 5. Pain prevents me from sitting at all. 4. I need help every day in most aspects of self-care. 5. I do not get dressed, wash with difficulty and stay in bed Lifting Standing 0. I can lift heavy weights without extra pain. 0. I can stand as long as I want without extra pain. 1. I can lift heavy weights but it gives extra pain. 1. I can stand as long as I want but it gives extra pain. 2. Pain prevents me from lifting heavy weights off the 2. Pain prevents me from standing more than one floor, but I can manage if they are conveniently hour. positioned. (e.g., on a table.) 3. Pain prevents me from standing more than thirty 3. Pain prevents me from lifting heavy weights, but I minutes. can manage light to medium weights if they are 4. Pain prevents me from standing more than ten conveniently positioned. minutes. 4. I can lift only very light weights. 5. Pain prevents me from standing at all. 5. I cannot lift or carry anything at all. CONTINUED ON NEXT PAGE Page 13 of 14 EFTA00313826 CI ColumbiaDoctors I Orthopedic Surgery Adult Spine Supplement Spine Sleeping Social life 0. Pain does not prevent me from sleeping well. 0. My social life is normal and gives me no extra pain. 1. I can sleep well only by using tablets. 1. My social life is normal but increases the degree of 2. Even when I take tablets I have less than six hours pain. sleep. 2. Pain has no significant effect on my social life apart 3. Even when I take tablets I have less than four hours from limiting my more energetic interests, (e.g., sleep. dancing, etc.). 4. Even when I take tablets I have less than two hours 3. Pain has restricted my social life and I do not go out sleep. as often. 5. Pain prevents me from sleeping at all. 4. Pain has restricted my social life to home. S. I have no social life because of pain. Employment/Homemaking Traveling 0. My normal homemaking/job activities do not cause pain. 0.I can travel anywhere without extra pain. 1. My normal homemaking/job activities increase my 1.I can travel anywhere but it gives extra pain. pain, but I can still perform all that is required of 2.Pain is bad but I manage journeys over two hours. me. 3.Pain restricts me to journeys less than one hour. 2. I can perform most of my homemaking/job duties, 4.Pain restricts me to short journeys under thirty but pain prevents me from performing more minutes. physically stressful activities. (e.g. lifting, 5. Pain prevents me from traveling except to the vacuuming). doctor or hospital. 3. Pain prevents me from doing anything but light duties. 4. Pain prevents me from doing even light duties. 5. Pain prevents me from performing any job or homemaking chores Office Use Only: Score Patient Signature and Date 2-4-1 Physician Signature and Date Page 14 of 14 EFTA00313827