Medical and Family History to Present to a Spine Surgeon or Spine Specialist

Basic information that your physician will probably ask for includes: your name, birthday, age, sex, marital status, and social security number, religion, race or ethnic group.

More extensive information will be requested regarding any other health problems, such as:

  • Do you have any chronic, recurrent health problems, aside from the back or neck?
  • If so, what is the diagnosis and how is it treated and by whom? Give details. Who is your doctor for this or any of the other problems listed above?

For any of the above, discuss the treatment, how often and from whom you are now being treated, such as:

  • Medications taken (listing medication name, strength, daily dosage, and purpose). For example, do you take aspirin, arthritis medicine, blood thinners, garlic tablets?
  • Do you use any injections?
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  • Have you had trouble with prescription drugs in the past? With non-prescription drugs?
  • Do you have allergies to any medications, food, etc?
  • Do you take herbal supplements or vitamins? If so, which ones and how often?
  • Alcohol intake, daily or monthly, kind of alcohol? Have you ever been treated for drug or alcohol dependency?
  • Have you had any recent unplanned weight loss or gain?
  • How is your dietary intake?
  • What surgeries have you had? When and by whom? Results? Complications?

Family History to Share with the Spine Specialist

You will probably be asked about information on your parents, siblings, children, and spouse and their health status or year and cause of death.

Specifically, you will probably be asked about:

  • Any family history of diabetes, high blood pressure, or liver, lung, kidney, heart, stomach, bowel, blood, bone, joint, muscle, stroke, or nervous system disorders.
  • Any arthritis in the family and age of onset - how diagnosed and how treated.
  • Any history of back/neck/spine problems in family - age of onset, how diagnosed and how treated, as well as the name of treating doctor and clinic.

Social, Occupational and Recreational History to Share with the Spine Specialist

You may be asked a number of questions about your general background and situation, such as:

  • Educational level reached
  • Occupational history with length of employment. Physical nature of the job. Working hours per week? Any illness or injury on the job? When? How diagnosed and treated? Any litigation (lawsuits or workmen's compensation issues) regarding the job? Do you have a lawyer involved?
  • Does your spouse work? Details?
  • Are you satisfied with your job? How do you get along with your supervisor or boss?
  • How do you get along with your spouse? Children? Siblings?
  • Psychological history - any diagnosis? Depression? How treated and for how long? Doctor's name and clinic. Does your spouse have any similar problems?
  • How is your anger or depression, if any? Recent change?
  • How well do you sleep? What do you need to get to sleep?
  • Activities: what sports or hobbies do you do now, what sports or hobbies have you given up?
  • Body weight now? Recent change?
  • How is your energy level now? Recent change?
  • Any recent infections (bladder, lung, etc.)?
  • Difficulty in controlling the bowel and/or bladder?
  • Past history of cancer?
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