Mir.wustl.edu

Revised 03/07/05
Mallinckrodt Institute of Radiology / Musculoskeletal Section
Baseline Vertebroplasty Patient Questionnaire
Patient Name:
Patient Street address:
City / Zip Code:
Home phone #:( ) ______________________ Work Phone #: ( )
Sex:________________ Weight:__________________
Date of birth:___________________ Social Security #:
Contact person other than the patient:_______________________ Phone#: ( )
Referring Physicians (if more than three, please put their information on the back of this questionnaire):
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Name:
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Name:
03-07-05
Circle Your Best Answer
Have you been diagnosed with a compression fracture? Which region or regions of the spine is your fracture(s) in? When did your fracture(s) occur? Approximate date: __________________________________ Do you have pain associated with this fracture(s)? If you have more than one fracture, which region(s) of the spine is painful? date:__________________________________________ Does the pain travel into your arms, thighs (above knees), legs (below knees)? Do you have numbness and/or tingling in your arms, thighs, legs, and/or groin? Do you use a cane or walker, to assist you? Please circle all treatments you have received for your current spine pain. Have you ever had steroid injections in your spine for this problem? If yes, what type of relief did the injection give? Complete relief Pain worse after injection 03-07-05
Please indicate what type, when and where your most recent imaging studies were taken:. Please list all pain medications you have taken for your spine pain in the past two weeks.
_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Please list all other medications you are taking (use back of page for additional medicines) _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Are you taking Aspirin or other blood thinners? : Yes If yes, how long have you taken oral steroids?___________________________ Have you had the diagnosis of osteoporosis prior to this fracture? If Yes, when were you diagnosed with osteoporosis?______________________________ If Yes, what treatment have you received for osteoporosis? Circle all those that apply: Pain medication injections Actonel, Calcitonin (Calcimar, Miacalcin) Evista, Forteo, Fosamax (If Yes, how long have you taken Fosamax? What was your height at age 25? ________________________ For women only, how old were you when you started menopause?_________________ Do you have any allergies to medication? If yes, please list allergies:_______________________________________________ Have you ever had an allergic reaction to contrast material (x-ray dye), iodine, or shellfish? If yes, please list what type of cancer: ____________________________________ 03-07-05
Please check all other medical problems you have. Medical History: Check all:
Is your primary doctor aware of the above checked problems?
If you have had spine surgery, please describe which region of the spine was involved and why surgery was Review of Systems: Check all.
Women
Only:
03-07-05
Please shade your areas of pain in the diagram below.

Source: http://www.mir.wustl.edu/graphics/assets/media/Procedures%20and%20Exams/Baseline%20Vertebrop%20Questionnaire.pdf